Inspection Reports for San Vicente Home Care
8460 Rancho Destino Rd., Las Vegas, NV 89123, NV, 89123
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Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 7
Jun 9, 2025
Visit Reason
The inspection was conducted as an annual State Licensure and complaint investigation survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including improper administration of suppositories by non-medical staff, incomplete medication management training for caregivers, failure to initial medication reviews by the administrator, inaccurate medication administration records, incomplete dementia care training, and inadequate infection control training for designated staff.
Complaint Details
One complaint (NV00074131) was investigated and found unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Caregiver assisted with insertion of suppositories without physician order or medical professional involvement for Resident #6. | Level 2 |
| One of three caregivers administering medications lacked the required initial 16 hours of medication management training. | Level 2 |
| Administrator failed to initial 6-month medication reviews for 8 of 10 residents. | Level 2 |
| Medication Administration Record (MAR) was inaccurate for 4 of 10 residents, including missed documentation and erroneous signatures. | Level 2 |
| One of five caregivers failed to complete the required three hours of Alzheimer's and Dementia Caregiver training. | Level 2 |
| Primary and secondary infection control staff failed to complete 15 hours of annual infection control training. | Level 2 |
| One of five caregivers failed to complete the required annual infection control training for unlicensed caregivers. | Level 2 |
Report Facts
Residents reviewed: 10
Employee files reviewed: 5
Complaint investigated: 1
Medication management training hours required: 16
Infection control training hours required: 15
Dementia training hours required: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Visitacion T. Dela Pena | Administrator | Named in relation to findings on medication administration, training deficiencies, and infection control |
| Employee #1 (E1) | Caregiver | Involved in improper suppository administration and lacked required medication training |
| Employee #3 (E3) | Administrator | Failed to complete required dementia and infection control training |
| Employee #4 (E4) | Caregiver | Failed to complete required annual infection control training for unlicensed caregivers |
| Employee #5 (E5) | Caregiver | Primary infection control person lacking required training; later terminated |
| Employee #2 (E2) | Caregiver | Replaced E1 to assist with medication passing after E1's training deficiency |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 1
Aug 7, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation completed on 08/07/2024 regarding concerns at the facility.
Findings
The investigation included observations, interviews, and record reviews. No regulatory deficiencies were identified overall, but a deficiency was found related to failure to complete an incident report for a resident who had fallen.
Complaint Details
One complaint was investigated (Complaint #NV00071625) and was substantiated. The investigation included observation of grooming and physical appearance, a tour of the facility, interviews with residents, caregivers, and the owner, and record review of five residents including the resident of concern.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure an incident report was completed for a resident who had fallen and sustained a bruise. | Severity: 2 |
Report Facts
Residents present: 9
Sample size: 8
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Visitacion T. Dela Pena | Administrator | Named in relation to the incident report deficiency and interview statements |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Jun 26, 2024
Visit Reason
The inspection was conducted as an Annual State Licensure survey of the residential facility for groups, to assess compliance with Nevada Administrative Code (NAC) Chapter 449.
Findings
The facility received a grade of A, but two regulatory deficiencies were identified: inaccurate Medication Administration Record (MAR) documentation for one resident and failure to obtain placement assessments for all nine residents reviewed.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure the Medication Administration Record (MAR) was accurate for Resident #7; the medication Sevelamer 800 mg was administered but not documented on the MAR. | 2 |
| The facility failed to obtain a placement assessment for 9 of 9 residents to determine appropriate placement. | 2 |
Report Facts
Residents present: 9
Licensed capacity: 10
Residents reviewed: 9
Employee files reviewed: 4
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 1
Apr 22, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints received by the facility.
Findings
Two complaints were investigated and substantiated with no deficient practice identified. However, a deficiency was found related to failure to complete an incident report for a resident who eloped from the facility.
Complaint Details
Two complaints were investigated: Complaint #NV00070683 and Complaint #NV00070804, both substantiated with no deficient practice. The deficiency related to the incident report was identified during the complaint investigation.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure an incident report was completed for a resident who eloped from the facility. | Severity: 2 |
Report Facts
Complaints investigated: 2
Sample size: 5
Date of elopement: Feb 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Visitacion T. Dela Pena | Administrator | Administrator interviewed and acknowledged the missing incident report for the elopement |
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 6
Mar 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00070530, focusing on allegations related to resident care, employee files, facility conditions, and safety compliance.
Findings
The facility was found deficient in multiple areas including incomplete employee files, improper housing of a live-in caregiver in a resident's bedroom closet, use of bed rails as restraints on residents, non-operational door alarms, and unsecured toxic substances. The complaint was substantiated with severity level 2 deficiencies.
Complaint Details
Complaint #NV00070530 was verified. The investigation included observations, interviews with residents, caregivers, and the administrator, and review of clinical and employee records. Deficiencies related to employee files, housing, restraints, alarms, and toxic substance security were found.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 Caregivers had a completed employee file including background check and training documentation. | Level 2 |
| Facility failed to ensure a resident bedroom closet was not used as a bedroom for an employee. | Level 2 |
| Facility failed to provide a bedroom for a live-in caregiver; caregiver was residing in a resident's bedroom closet. | Level 2 |
| Facility failed to ensure bed rails were not used as restraints for 2 residents. | Level 2 |
| Facility failed to ensure door alarms were operating; back door alarm was turned off. | Level 2 |
| Facility failed to ensure toxic substances were secured; multiple toxic substances were unsecured in a resident bedroom closet. | Level 2 |
Report Facts
Resident census: 10
Total licensed capacity: 10
Sample size: 5
Sample size: 6
Severity 2 deficiencies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Visitacion Dela Pena | Administrator | Named as Administrator who acknowledged deficiencies and oversaw plan of correction |
| Employee #1 | Caregiver | Identified as caregiver lacking employee file, residing improperly in resident closet, and involved in multiple deficiencies |
| Employee #4 | Confirmed use of bed rails as restraints and acknowledged alarm issues |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 8
Jun 28, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including failure to provide ramps for residents with restricted mobility, medication administration errors, failure to notify physicians of missed medications, inaccurate medication administration records, unsecured sharp objects and toxic substances, and incomplete employee training on dementia care and cultural competency.
Severity Breakdown
Level 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure ramps were available for a resident using a wheelchair to safely access the sunken living room. | Level 2 |
| Failed to administer medication as prescribed for a resident, including lack of documented physician discontinue orders and failure to follow medication timing instructions. | Level 2 |
| Failed to notify physician within 12 hours when a resident refused or missed medication doses. | Level 2 |
| Medication Administration Record (MAR) was inaccurate for three residents, including missed documentation and expired medications on site. | Level 2 |
| Failed to secure sharp objects accessible to residents, including scissors found unlocked in a bathroom drawer. | Level 2 |
| Failed to secure toxic substances accessible to residents, including various creams and patches found unsecured in resident rooms. | Level 2 |
| Failed to ensure one employee completed required dementia care training within the past 12 months. | Level 2 |
| Failed to ensure cultural competency training was compliant and completed by all employees, with one employee completing training from an unapproved course. | Level 2 |
Report Facts
Residents present: 9
Total licensed beds: 10
Deficiencies cited: 8
Employees reviewed: 4
Resident files reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Visitacion Dela Pena | Administrator | Named in relation to findings and responsible for ensuring plans of correction |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 8
Jun 28, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey of the residential facility for groups, to assess compliance with Nevada Administrative Code Chapter 449.
Findings
The facility was found to have multiple regulatory deficiencies including failure to provide ramps for wheelchair access, medication administration errors, failure to notify physicians of missed medications, inaccurate medication administration records, unsecured sharp objects and toxic substances, and incomplete employee training on dementia care and cultural competency.
Severity Breakdown
Level 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure ramps were available for a resident using a wheelchair to safely access the sunken living room. | Level 2 |
| Failed to administer medication as prescribed for one resident, including lack of documented discontinue orders and failure to follow physician instructions. | Level 2 |
| Failed to notify physician within 12 hours when a resident refused or missed medication doses. | Level 2 |
| Medication Administration Record (MAR) was inaccurate for three residents, including missed documentation and expired medications on site. | Level 2 |
| Failed to ensure sharp objects were secured and inaccessible to residents, with scissors found unsecured in a bathroom drawer. | Level 2 |
| Failed to ensure toxic substances were secured and inaccessible to residents, with multiple creams and patches unsecured in resident rooms. | Level 2 |
| Failed to ensure one employee completed required dementia care training within the past 12 months. | Level 2 |
| Failed to ensure cultural competency training was compliant with regulations; one employee completed training from an unapproved course. | Level 2 |
Report Facts
Residents present: 9
Total licensed capacity: 10
Deficiencies cited: 8
Employee files reviewed: 4
Resident files reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Visitacion Dela Pena | Administrator | Named in relation to findings and responsible for ensuring plans of correction |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Mar 8, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints at the facility.
Findings
Both complaints were substantiated but no deficient practices or regulatory deficiencies were identified. Observations, interviews, and record reviews showed no issues requiring further action.
Complaint Details
Two complaints were investigated: Complaint #NV00067754 and Complaint #NV00067914, both substantiated with no deficient practice.
Report Facts
Sample size: 5
Complaints investigated: 2
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Jun 14, 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 was provided guidance on nondiscrimination, privacy, cultural competency, and complaint policies.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Aug 9, 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 with no deficiencies identified. Guidance was provided on compliance with NRS 449.101, NRS 449.102, and LCB File No. R016-20 regarding discrimination, privacy, and cultural competency policies.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Aug 9, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey for re-licensure of the facility.
Findings
The facility was found to be in substantial compliance with regulations, with no deficiencies identified and received a grade of A.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 6
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Aug 9, 2016
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 08/09/2016 by the Division of Public and Behavioral Health.
Findings
The facility was found to be in substantial compliance with regulations, with no deficiencies identified. The facility received a grade of A.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 6
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Nov 12, 2015
Visit Reason
This inspection was conducted as a complaint investigation following allegations regarding caregiver training, employee background checks, supervision of residents, resident dignity and respect, and provision of activities.
Findings
The investigation included observations, interviews, and record reviews, and found that none of the allegations were substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00044358 included five allegations which were all found to be unsubstantiated: lack of caregiver training, failure to conduct background checks, lack of supervision, residents not treated with dignity or respect, and lack of activities for residents.
Report Facts
Sample size: 5
Number of complaints investigated: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Sep 14, 2015
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 9/14/2015 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A with no regulatory deficiencies identified during the survey.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 6
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Sep 23, 2014
Visit Reason
This inspection was a State Licensure annual grading survey conducted at the facility on 9/23/14 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with deficiencies identified related to personnel background checks, medication storage, and securing dangerous items. The facility failed to ensure one employee complied with background checks, medications were not properly locked, and dangerous items were accessible to residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 7 employees complied with the required background check. | Severity: 2 Scope: 1 |
| Facility failed to ensure medications were kept in a locked container; unlocked container with medications was found. | Severity: 2 Scope: 3 |
| Facility failed to ensure dangerous items such as scissors, razor, and rubbing alcohol were inaccessible to residents. | Severity: 2 Scope: 3 |
Report Facts
Resident census: 10
Total licensed capacity: 10
Number of employees reviewed: 6
Number of resident files reviewed: 9
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Sep 23, 2014
Visit Reason
This inspection was conducted as a State Licensure annual grading survey of the facility on 09/23/2014.
Findings
The facility received a grade of B with deficiencies identified related to personnel background checks, medication storage, and accessibility of dangerous items to residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 7 employees complied with the required background check. | Severity: 2 |
| Failed to ensure medications were kept in a locked container; unsecured medications found in hall closet and resident bedroom. | Severity: 2 |
| Failed to ensure dangerous items such as scissors, meat tenderizer, razors, and rubbing alcohol were inaccessible to residents. | Severity: 2 |
Report Facts
Number of residents present: 10
Total licensed capacity: 10
Number of employee files reviewed: 6
Number of resident files reviewed: 9
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 6
Oct 16, 2013
Visit Reason
The inspection was a State Licensure annual grading survey conducted to evaluate compliance with regulations for a residential facility for elderly and disabled persons and/or persons with Alzheimer's disease.
Findings
The facility received a grade of B with several deficiencies identified including failure to ensure annual medication management training for one caregiver, failure to treat one resident in a considerate manner, failure to maintain medications at a maintenance level requiring medical assessment, improper medication labeling and storage, and unsecured medications in resident rooms.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| One caregiver failed to complete the required 8 hours of annual medication management refresher training. | Severity: 2 |
| One resident was not treated in a considerate manner; administrator yelled at resident causing emotional distress. | Severity: 2 |
| One resident's medications were not at a maintenance level and required medical assessment before administering. | Severity: 2 |
| Label on medication bottle was incorrect; administrator to ensure future orders have separate bottles for routine and PRN medications. | Severity: 2 |
| One resident received prescribed medication not on site; medication administration record listed it as routine medication without physician contact. | Severity: 2 |
| Medications were not stored in a locked container; unsecured over-the-counter medications found in resident rooms and filing cabinet. | Severity: 2 |
Report Facts
Residents present: 10
Licensed capacity: 10
Caregivers reviewed: 8
Resident files reviewed: 10
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vivatacion T. Salcema | RN Administrator | Named as Administrator and signer of the report; involved in findings related to resident treatment and medication administration |
| Employee #1 | Failed to complete annual medication training; involved in medication and resident treatment deficiencies |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 5
Oct 16, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulatory requirements 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 medication training, failure to treat residents considerately, failure to comply with medication administration requirements, and failure to properly secure medications.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 5 caregivers completed the required 8 hours of annual medication management refresher training. | Severity: 2 |
| Failure to ensure 1 of 10 residents was treated in a kind and considerate manner; Administrator yelled at resident causing emotional distress. | Severity: 2 |
| Failure to comply with medication administration requirements; 1 of 10 residents' medications were not at maintenance level and required medical assessment before administering. | Severity: 2 |
| Failure to ensure 1 of 10 residents received medications as prescribed; medication not on site and no documented physician contact. | Severity: 2 |
| Failure to ensure medications were stored in a locked container; unsecured medications found for multiple residents. | Severity: 2 |
Report Facts
Residents present: 10
Total licensed capacity: 10
Employee files reviewed: 8
Resident files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Named in findings related to medication training deficiency and resident treatment deficiency |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Oct 1, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 10/01/2012.
Findings
The facility received a grade of A. Two deficiencies were identified: one related to personnel files missing a 2012 annual tuberculosis skin test for one employee, and another related to a non-operational alarm on one of four exit doors.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 employees complied with tuberculosis testing requirements (missing 2012 annual TB skin test). | Severity: 2 |
| Facility failed to ensure 1 of 4 exit doors had an operational alarm (back patio exit door alarm needed new battery). | Severity: 2 |
Report Facts
Number of resident files reviewed: 9
Number of employee files reviewed: 6
Number of beds licensed: 10
Number of exit doors: 4
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