Inspection Reports for Santa Fe Care Home
4621 Exposition Ave, Las Vegas, NV 89102, NV, 89102
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: 7
Deficiencies: 1
Nov 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00072275, which was substantiated. The investigation included observations, interviews, and record reviews related to the complaint.
Findings
The facility was found to have roach traps containing dead cockroaches placed improperly on kitchen countertops, which is a violation of sanitary kitchen equipment requirements. Pest control services were called and corrective actions were planned.
Complaint Details
One complaint was investigated and substantiated: Complaint #NV00072275.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Kitchen countertops had roach traps containing dead cockroaches, violating sanitary preparation requirements. | Severity: 2 |
Report Facts
Census: 7
Sample size: 3
Complaint count: 1
Severity level: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Romeo V Balgan | Administrator | Named as responsible person for ensuring plan of correction implementation |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Sep 18, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation initiated on 2024-09-04 and completed on 2024-09-18.
Findings
The facility received a grade of A. Two complaints were investigated and found unsubstantiated with no regulatory deficiencies identified. However, regulatory deficiencies were found related to medication administration, including failure to ensure six-month medication reviews were initialed and dated by the Administrator within 72 hours for 3 residents, and incomplete documentation on the Medication Administration Record for one resident.
Complaint Details
Two complaints (#NV00072047 and #NV00072064) were investigated and both were unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure six-month Medication Reviews were initialed and dated by the Administrator within 72 hours for 3 of 9 residents (Residents #1, #2, and #3). | Level 2 |
| Medication Administration Record (MAR) lacked accurate documentation for 1 of 9 resident's medications (Resident #1) for morphine sulfate ER 15 mg tablets administered at 8:00 PM from 09/01/24 through 09/03/24. | Level 2 |
Report Facts
Licensed capacity: 10
Census: 9
Complaints investigated: 2
Residents reviewed: 10
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Romeo V Balgan | Administrator | Named in relation to medication administration deficiencies and responsible for plan of correction. |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 9
Nov 29, 2023
Visit Reason
This inspection was conducted as an annual State Licensure grading resurvey of a residential facility for groups, in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A. Several regulatory deficiencies were identified including issues with medication administration, personnel files, health and sanitation maintenance, and documentation accuracy. Deficiencies were generally rated at severity level D or E, with one deficiency rated at severity level F.
Severity Breakdown
D: 6
E: 1
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Qualifications of Caregiver - Med Training not fully compliant; Employee #4 had training on December 18, 2023. | D |
| Personnel Files - Background Checks incomplete; Employee #4 obtained background checks. | D |
| Health & Sanitation - Facility interior and exterior maintenance issues; backyard weeds removed but ongoing maintenance needed. | F |
| First Aid & CPR training completed by Employee #4; files need regular updates. | D |
| Medication Administration - Failed to ensure medications were prescribed at maintenance level and daily assessments were not consistently performed for Resident #3. | D |
| Medication/OTCS, Supplements, Change Order - Resident #3 medications not ordered or administered as prescribed due to hospice and transfer. | D |
| Medication Destruction - Expired medication not destroyed timely for Resident #1. | D |
| Administration of Medication Maintenance - Medication Administration Record (MAR) inaccurate for Residents #2 and #3; documentation incomplete. | E |
| Cultural Competency Training completed by Employee #4 on October 5, 2023; ongoing monitoring required. | D |
Report Facts
Licensed capacity: 10
Current census: 8
Severity level D deficiencies: 6
Severity level E deficiencies: 1
Severity level F deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Named in multiple findings related to medication training, background checks, first aid and CPR training, cultural competency training, and medication administration. | |
| Romeo V Balgan | Administrator | Facility Administrator responsible for ensuring implementation of plans of correction. |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 8
Sep 11, 2023
Visit Reason
The inspection was an annual grading State Licensure survey conducted in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of C with multiple regulatory deficiencies identified including failure to ensure annual medication management training, background checks, first aid and CPR certification, cultural competency training for an employee, maintenance issues with the facility premises, and medication administration and documentation errors for residents.
Severity Breakdown
2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees had annual Medication Management Training. | 2 |
| Failed to ensure 1 of 4 employees completed a current background check through the Nevada Automated Background Check System. | 2 |
| Failed to ensure the interior and exterior of the facility was well maintained, including backyard weeds, unfinished glass wall, and dirty skylight mesh. | 2 |
| Failed to ensure 1 of 4 employees was certified in first aid and cardiopulmonary resuscitation (CPR). | 2 |
| Failed to ensure medications were prescribed at a maintenance level and did not require daily assessment for 1 of 9 residents. | 2 |
| Failed to ensure medications were onsite and given as prescribed for 1 of 9 residents. | 2 |
| Failed to ensure medications were accurately documented and initialed on the Medication Administration Record for 2 of 9 residents. | 2 |
| Failed to ensure 1 of 4 employees had training in cultural competency within 30 days of hire. | 2 |
Report Facts
Licensed capacity: 10
Census: 9
Employees reviewed: 4
Residents reviewed: 9
Deficiencies with severity 2: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Caregiver | Named in multiple findings including lack of annual medication management training, background check, first aid and CPR certification, and cultural competency training. |
| Romeo Villanueva Balgan | Administrator | Named as responsible for ensuring implementation of plans of correction. |
Inspection Report
Re-Inspection
Census: 7
Capacity: 10
Deficiencies: 11
Nov 7, 2022
Visit Reason
This inspection was a mandatory grading resurvey conducted at the facility on 11/07/22 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A. Several regulatory requirements related to staffing schedules, personnel files, health and sanitation, activities for residents, oxygen use, medication administration, medication storage, discrimination prohibition, and cultural competency training were reviewed with varying severity levels noted.
Severity Breakdown
F: 4
D: 3
C: 3
E: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Administrator's Responsibilities - Designation - NAC 449.194 Responsibilities of administrator. | F |
| Staffing Schedule - NAC 449.199 Staffing requirements. | C |
| Personnel File - TB Screening - NAC 449.200 Personnel files. | E |
| Health & Sanitation - Maintain Int/ext - NAC 449.209 Health and sanitation. | F |
| Activities for Residents - NAC 449.260 Activities for residents. | C |
| Residents Requiring Use of Oxygen - NAC 449.2712 Residents requiring use of oxygen. | F |
| Medication/OTCS, Supplements, Change Order - NAC 449.2742 - Administration of medication: Responsibilities of administrator, caregiver and employees of facility. | D |
| Administration of Medication Maintenance - NAC 449.2744 Administration of medication: Maintenance and contents of logs and records. | D |
| Medication: Storage - NAC 449.2748 Medication: Storage; duties upon discharge, transfer and return of resident. | D |
| Discrimination prohibited | C |
| Cultural Competency Training | F |
Report Facts
Licensed beds: 10
Residents present: 7
Grade: A
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 10
Sep 14, 2022
Visit Reason
The inspection was conducted as an annual grading and infection control State Licensure survey in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of D with multiple regulatory deficiencies identified including failure to post the designee in charge letter, lack of staffing schedules for the past six months, incomplete personnel files regarding physical exams, backyard clutter and debris, unsecured oxygen canisters, medication administration and storage issues, lack of current activity calendar, missing nondiscrimination statement, and absence of cultural competency training program.
Severity Breakdown
Severity: 1: 3
Severity: 2: 7
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to post the designee in charge letter in a conspicuous location. | Severity: 1 |
| Failed to ensure current and previous six months of staffing schedules were available. | Severity: 1 |
| Failed to ensure physical exams were completed prior to hire for 2 of 3 employees. | Severity: 2 |
| Backyard was not free of debris and broken equipment including broken bed frames, wheelchairs, mattresses, and trash. | Severity: 2 |
| Failed to ensure oxygen canisters were properly secured; three unsecured canisters found. | Severity: 2 |
| Failed to ensure medication was onsite for 1 of 8 residents; Atropine Sulfate ointment missing. | Severity: 2 |
| Medication Administration Record (MAR) lacked initials to indicate medications were administered for 1 of 8 residents. | Severity: 2 |
| Failed to ensure all medications were locked and unavailable to 1 of 8 residents; Prednisolone 1% solution found at bedside without active order. | Severity: 2 |
| Failed to ensure a non-discrimination statement was posted. | Severity: 1 |
| Failed to submit or provide evidence of a cultural competency training program for employees. | Severity: 2 |
Report Facts
Licensed capacity: 10
Current census: 8
Number of resident files reviewed: 8
Number of employee files reviewed: 3
Number of unsecured oxygen canisters: 3
Number of residents with medication issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Romeo Balgan | Administrator | Named as the facility administrator responsible for implementing plans of correction. |
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 0
Dec 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00065100 regarding an allegation that the facility discharged a resident requiring care to an unlicensed facility.
Findings
The complaint allegation was unsubstantiated based on interviews with staff and review of resident and physician documentation. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00065100 with one allegation was investigated and found unsubstantiated. The allegation that the facility discharged a resident requiring care to an unlicensed facility was not supported by evidence.
Report Facts
Licensed capacity: 10
Sample size: 2
Complaints investigated: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Oct 7, 2021
Visit Reason
The inspection was conducted as an annual grading and infection control survey of the facility in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to failure to ensure one resident had current physical examinations and failure to ensure medication reviews were completed every six months for three residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 9 residents had current physical examinations upon admission and annually. | Severity: 2 |
| Facility failed to ensure medication reviews were completed every six months for 3 of 9 residents. | Severity: 2 |
Report Facts
Residents reviewed: 9
Employee files reviewed: 3
Medication review overdue residents: 3
Residents missing physical exams: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Romeo V Balgan | Administrator | Signed the inspection report and responsible for plan of correction |
| Employee #2 acknowledged missing physical exams and medication reviews but no full name provided |
Inspection Report
Abbreviated Survey
Census: 5
Capacity: 10
Deficiencies: 1
Oct 28, 2020
Visit Reason
The inspection was a COVID-19 focused infection control survey conducted to assess the facility's compliance with infection control policies and procedures during the pandemic.
Findings
The facility lacked comprehensive COVID-19 infection control policies, did not screen visitors properly according to CDC guidelines, had insufficient PPE supplies including no N95 masks, and staff were not medically cleared or fitted for N95 masks. The Administrator did not ensure proper visitor screening and the facility did not provide COVID-19 infection control training to employees.
Severity Breakdown
Severity: 2 Scope: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator did not ensure visitors were screened for COVID-19 according to CDC guidelines prior to entry and the facility lacked comprehensive policies for protection of residents in response to COVID-19. | Severity: 2 Scope: 3 |
Report Facts
Licensed capacity: 10
Census: 5
PPE inventory: 1
PPE inventory: 2
Completion date: Nov 18, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Romeo V Balgan | Administrator | Named as Administrator responsible for oversight and plan of correction |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 4
Feb 17, 2016
Visit Reason
The inspection was an annual State Licensure grading survey conducted to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with several deficiencies identified including incomplete tuberculosis testing for employees, missing background check clearances, maintenance issues such as broken kitchen drawers and improperly stored oxygen tanks, and medication administration errors for one resident.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees completed tuberculosis (TB) testing requirements. | Level 2 |
| Failure to ensure 3 of 4 employees completed background check requirements. | Level 2 |
| Failure to maintain clean and safe interior and exterior premises, including broken kitchen drawers, improperly stored oxygen tanks, and soda cans stored in a plastic bag. | Level 2 |
| Failure to ensure 1 of 8 residents was administered medication following physician's order. | Level 2 |
Report Facts
Residents present: 8
Total licensed capacity: 10
Employees reviewed: 4
Resident files reviewed: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 4
Feb 17, 2016
Visit Reason
This annual State Licensure grading survey was conducted on 2/17/16 to assess compliance with state regulations for the facility licensed for ten Residential Facility for Group beds.
Findings
The facility received a grade of B with several regulatory deficiencies identified, including incomplete tuberculosis testing and background checks for employees, failure to maintain clean and safe premises, and medication administration not fully following physician's orders.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees completed tuberculosis testing requirements. | 2 |
| Failed to ensure 3 of 4 employees completed background check requirements. | 2 |
| Failed to ensure the interior and exterior premises were clean and safe, including broken kitchen drawers, improper storage of oxygen tanks and wheelchair foot rests, and trash in the backyard. | 2 |
| Failed to ensure 1 of 8 residents was administered medication following physician's order regarding Albuterol dosing schedule. | 2 |
Report Facts
Facility licensed beds: 10
Current census: 8
Employee files reviewed: 4
Resident files reviewed: 8
Inspection Report
Original Licensing
Capacity: 10
Deficiencies: 0
Mar 3, 2014
Visit Reason
This inspection was conducted as an initial State licensure survey for Santa Fe Care Home I to be licensed for ten Residential Facility for Group beds for elderly and disabled persons and/or persons with mental illness.
Findings
Deficiencies were found at the time of the inspection but were corrected. Two employee files were reviewed during the survey.
Report Facts
Licensed beds: 10
Category 1 residents: 5
Category 2 residents: 5
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