Las Ventanas Retirement Comm SNF

In the surveyor’s words

From the most serious findings on record at Las Ventanas Retirement Comm SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 1, 2022

  Based on observation, interview and document review, the facility failed to ensure food was stored in a manner to prevent food related illness. On 06/28/2022 at 10:48 AM, an inspection of the kitchen conducted with the Director of Dining Services revealed the following items stored in the walk-in freezer without the respective label indicating the start date and use by date: A box of fish fillets was open and exposed to air. A bag of pepperoni. A bag containing single-serve butter pats. The Director of Dining Services confirmed the observation and acknowledged the open packets of food should have been labeled and covered. The facility policy titled Food Supply and Storage dated January 2021, documented unused portions and open packets should be covered, labeled, and dated.

• No harm, potential for more than minimal, isolatedF578Jun 11, 2026

  Based on interview, record review, and document review, the facility failed to document a Nurse Practitioner license number on a Provider Order for Life-Sustaining Treatment (POLST) form for 1 of 29 residents (Resident 65). The deficient practice had the potential to result in uncertainty regarding the validity of the POLST and the resident's end of life treatment preferences. Findings include:Resident 65 (R65) was admitted [DATE], with diagnosis including chronic obstructive pulmonary disease, anxiety disorder, and nausea with vomiting.R65's electronic medical record documented Do Not Resuscitate (DNR) POLST, Medical Interventions Comfort-Focused Treatment, No Hospitalizations.A review of R65's POLST form revealed it was signed by a Nurse Practitioner (NP) on 04/20/2025 and the signature… […]

• No harm, potential for more than minimal, isolatedF677Jun 11, 2026

  Based on observation, interview, record and document review the facility failed to provide foot care or treatments for 1 of 29 residents (Resident 48) who exhibited dry, flaky, and non-viable (dead) skin on both feet. The deficient practice had the potential to cause pain, infection, skin breakdown, and compromised mobility.Findings include:Resident 48 (R48) was admitted on [DATE] with diagnoses including chronic diastolic (congestive) heart failure. On 06/10/2026 at 10:42 AM, R48's right and left feet exhibited poor skin integrity, characterized by dry, flaky, non viable (dead) skin in the interdigital spaces and on the plantar surfaces. On 06/10/2026 at 10:45 AM, R48 indicated nursing assistants did not wash or apply lotion to either foot. […]

• No harm, potential for more than minimal, isolatedF690Jun 11, 2026

  Based on observation, interview, record review and document review, the facility failed to ensure physician orders were followed for an indwelling urinary catheter and documentation requirements were met in accordance with facility policy for 1 of 29 sampled residents (Resident 33). The deficient practice placed residents at risk for catheter-related complications.Findings include:Resident 33 (R33) was admitted on [DATE], with diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia.On 06/10/2026 in the morning, R33 laid in bed conversing with a family member. A covered urinary bag was observed hanging on the left side of the bed. […]

• No harm, potential for more than minimal, isolatedF694Jun 11, 2026

  Based on observation, interview, record review and document review, the facility failed to ensure a peripheral intravenous access (IV) had a dated dressing, and care orders for site assessment and dressing changes were transcribed and carried out for the peripheral IV line and a peripherally inserted central line (PICC) line for 2 of 29 sampled residents (Resident 4 and 45). The deficient practice placed residents at risk for phlebitis (site infection) and sepsis.Findings include:Resident 4 (R4) was admitted on [DATE] with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA) and malignant neoplasm of the bladder.On 6/10/2026 at 10:46 AM, R4 laid in bed appearing weak but able to articulate needs. […]