Inspection Reports for South Meadows Residential Care Home
13495 Stoneybrook Dr, Reno, NV 89511, United States, NV, 89511
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 9
Capacity: 10
Deficiencies: 7
Oct 28, 2024
Visit Reason
This inspection was a State Licensure grading re-survey conducted 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 with several deficiencies identified including issues with service of food, fire safety compliance, medication administration records, maintenance of resident files, discrimination policies, annual resident assessments, and infection control training. A significant deficiency was the failure to obtain an annual Standard Physician Assessment and Placement Determination for one resident with dementia.
Severity Breakdown
D: 5
C: 1
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Service of Food-Nutritious Meals; Frequency - Meals must be nutritious, served appropriately, and meet individual preferences and religious requirements. | D |
| Requirements and Precautions regarding safety from fire; facility must comply with State Fire Marshal regulations. | D |
| Administration of Medication Maintenance - maintaining accurate medication records including administration times and refusals. | D |
| Maintenance and Contents of Separate File for each resident; files must be kept locked and contain all relevant records. | D |
| Discrimination prohibited - facility must develop and carry out policies to prevent discrimination and post nondiscrimination statements. | C |
| Annual Assessment of History of Each Resident - failure to obtain annual Standard Physician Assessment and Placement Determination for Resident #5. | D |
| Infection Control Required Training - designated persons must complete at least 15 hours of infection control training within 3 months of designation and annually thereafter. | F |
Report Facts
Licensed beds: 10
Residents present: 9
Resident records reviewed: 6
Employee files reviewed: 2
Severity 2 deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nucharee Yokdang | Administrator | Named in relation to the failure to obtain annual Standard Physician Assessment and Placement Determination and responsible for plan of correction |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 7
Aug 22, 2024
Visit Reason
This inspection was a State Licensure annual grading survey conducted to assess compliance with Nevada Administrative Code for Residential Facility for Groups.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to complete required infection control training, expired food items in pantry, lack of monthly smoke detector testing, inaccurate medication administration records, incomplete tuberculosis testing, missing nondiscrimination statement on the website, and delayed initial physician assessment and placement determination for a resident.
Severity Breakdown
Severity: 2: 6
Severity: 1: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Infection control staff failed to complete required 15 hours of infection control training. | Severity: 2 |
| Expired canned goods were stored in the facility's pantry beyond the best by date. | Severity: 2 |
| Smoke detectors were not tested and recorded on a monthly basis; last test was in 2022. | Severity: 2 |
| Medication Administration Record (MAR) was inaccurate for Resident #7; medication not documented correctly. | Severity: 2 |
| Resident #7 lacked required two-step tuberculosis testing documentation. | Severity: 2 |
| Facility lacked required nondiscrimination statement on the Internet website used to market the facility. | Severity: 1 |
| Initial Standard Physician Assessment and Placement Determination for Resident #7 was completed three days after admission. | Severity: 2 |
Report Facts
Deficiencies cited: 7
Facility licensed capacity: 10
Current census: 9
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Sep 19, 2023
Visit Reason
This inspection was conducted as a State Licensure annual grading 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 regulatory deficiencies including failure to remove expired medication from use, unsecured resident records causing potential unauthorized access, and failure to ensure one employee completed initial cultural competency training within 30 days of hire.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure an expired medication was removed from use for 1 of 10 residents (Resident #4). | Level 2 |
| Failed to ensure resident records were secured causing potential for unauthorized access to the records. | Level 2 |
| Failed to ensure 1 of 4 employees completed initial cultural competency training within 30 days of hire. | Level 2 |
Report Facts
Residents present: 10
Licensed capacity: 10
Employee records reviewed: 4
Resident records reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nucharee Yokdang | Manager | Named as manager responsible for corrective actions and plan of correction |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Oct 6, 2022
Visit Reason
This inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A and no further action was necessary.
Inspection Report
Follow-Up
Census: 10
Capacity: 10
Deficiencies: 0
Apr 12, 2022
Visit Reason
This inspection was a follow-up State Licensure Survey conducted to verify compliance with residential facility regulations under NAC 449 for a Residential Facility for Groups.
Findings
The facility was found to be in full compliance with no deficiencies identified. The facility received a grade of A, and no further action was necessary.
Report Facts
Resident files reviewed: 10
Licensed capacity: 10
Census: 10
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 9
Dec 22, 2021
Visit Reason
This inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of C with multiple regulatory deficiencies identified including failure to obtain mental illness endorsement, maintenance issues, expired food, late or missing physical exams and assessments, medication administration and destruction issues, and incomplete resident files.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to obtain an endorsement for Mental Illness (MI) and admitted a resident with MI diagnosis without endorsement. | Level 2 |
| Failed to maintain interior premises; hall closet doors off track. | Level 2 |
| Failed to discard outdated food; expired parmesan cheese found. | Level 2 |
| Failed to ensure 2 residents received physical examinations upon admission and annually thereafter. | Level 2 |
| Medication profile reviews not initialed by Administrator for 8 residents. | Level 2 |
| Failed to destroy discontinued medication for one resident. | Level 2 |
| Failed to obtain Standard Physician's Assessment and Placement Determination upon admission for one resident. | Level 2 |
| Failed to ensure Activities of Daily Living (ADL) Assessment was completed upon admission for one resident. | Level 2 |
| Failed to ensure residents with dementia had standard placement determination completed prior to admission for four residents. | Level 2 |
Report Facts
Facility licensed beds: 10
Resident census: 10
Grade: C
Resurvey application fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nucharee Yokdang | Manager | Named as responsible for ensuring plan of correction implementation |
Inspection Report
Routine
Census: 8
Capacity: 10
Deficiencies: 0
Mar 3, 2021
Visit Reason
The inspection was conducted as a State Licensure COVID-19 Focused Infection Control Survey to assess infection control practices and compliance with COVID-19 related regulations at the facility.
Findings
The facility was found to have appropriate infection control measures in place including PPE use, hand hygiene, cleaning protocols, resident cohorting, and staff training. No regulatory deficiencies were identified during the survey.
Report Facts
Infection control supplies: 11
Infection control supplies: 5
Infection control supplies: 10
Infection control supplies: 600
Infection control supplies: 16
Infection control supplies: 6
Infection control supplies: 1
Infection control supplies: 3
Residents tested positive for COVID-19: 3
Residents tested negative for COVID-19: 5
Employees completed infection control training: 3
Cleaning frequency: 3
Cleaning frequency: 2
Staff quarantine duration: 21
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
Nov 13, 2020
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint# NV00062214 involving allegations related to visitation restrictions and untreated pressure sores.
Findings
The investigation found that neither allegation was substantiated; the facility's COVID-19 visitation policy was followed, and no evidence of untreated pressure sores was found. No regulatory deficiencies were identified and no further action was required.
Complaint Details
Complaint# NV00062214 included two allegations: 1) a resident's family was not allowed to visit while on hospice, which was not substantiated due to policy compliance and family violation of mask and distancing rules; 2) a resident had an untreated pressure sore, which was not substantiated due to lack of documented evidence.
Report Facts
Resident records reviewed: 8
Complaint number: NV00062214
Inspection Report
Follow-Up
Census: 9
Capacity: 10
Deficiencies: 0
Sep 16, 2020
Visit Reason
This inspection was a follow-up State Licensure COVID-19 Infection Control and Prevention Plan Survey conducted to assess the facility's compliance with infection control requirements during the COVID-19 pandemic.
Findings
The facility maintained appropriate COVID-19 infection control measures including screening, PPE use, social distancing, cleaning protocols, and staff training. The Infection Control and Prevention Plan was documented and ready for implementation with no regulatory deficiencies identified.
Report Facts
Licensed beds: 10
Resident census: 9
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