Every finding on record at Las Ventanas Retirement Comm SNF

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 was not legible. The required provider license number field for a Physician/Advanced Practice Registered Nurse (APRN)/Physician's Assistant (PA) license number was left blank.On 06/11/2026 at 7:45 AM, the Director of Staff Development (DSD) confirmed R65's POLST lacked the NP's license number. The DSD explained the Interdisciplinary Team should have reviewed R65's chart, including the POLST on admission to identify discrepancies or missing information. The DSD explained the provider license number was required on the POLST to validate the authorized provider was aware of the order and the resident's end of life choices. The DSD acknowledged the POLST's provider license number field should not have been left blank.On 06/11/2026 at 12:30 PM, the Director of Nursing (DON), confirmed R65's POLST lacked the NP's license number. The DON acknowledged the license number was required to identify and verify the provider authorized to sign the form. The DON acknowledged the POLST form should have included the required provider license number. The POLST form indicated, Bolded items are required. Under Validating Signatures Required, the provider's signature, printed name, and license number were identified as required fields.A facility policy titled Advanced Directives revised September 2022, documented a Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form was a form designed to improve patient care by creating a portable medical order form that records patient treatment wishes so that the emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration.

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. R48 reported when requesting these care tasks, staff express there was no time to perform foot hygiene or apply lotion.On 06/10/2026 at 2:30 PM, a Certified Nursing Assistant acknowledged R48's feet were dry and have non viable (dead) skin present.On 06/10/2026 at 2:34 PM, a Licensed Practical Nurse, confirmed that R48's right and left feet required foot care and acknowledged the resident's feet exhibited extremely dry skin.On 06/10/2026 at 2:48 PM, the Director of Nursing confirmed R48's feet were dry and had not been cared for. Director of Nursing acknowledged foot care should have been completed as part of R48s routine care.On 06/10/2026 at 2:59 PM, R48s care plan lacked documentation of routine foot care interventions, and there was no evidence of referral to qualified professionals despite visible skin abnormalities.On 06/10/2026 at 3:00 PM, record review revealed R48's medical record did not contain any documented physician orders for foot care.On 06/10/2026 at 3:10 PM, record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R48 required substantial and maximal assistance with personal hygiene.The facility's policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018, documented appropriate care and services would be provided to residents who were unable to perform ADLs independently.

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. A clinical admission assessment dated [DATE], revealed R33 was admitted with an indwelling catheter for urinary retention size 26 French (Fr -diameter size).A physician order dated 04/30/2026, documented urinary catheter 30 Fr/20 cubic centimeters (cc) balloon (amount of sterile waiter used for inflation), as needed for occlusion or leakage as needed.An admission note dated 04/30/2026 revealed R33 was admitted with a three-way Foley catheter size 30 Fr/20 cc balloon which was intact and draining clear yellow urine.On 06/11/2026 at 11:38 AM, the Registered Nurse (RN) assigned to R33 entered the resident's room, viewed R33's Foley catheter and confirmed R33 had a 16 Fr/10 cc Foley catheter. The RN could not speak to why the observation did not align with physician order for a 30 Fr/20cc and deferred to the Licensed Practical Nurse (LPN) who inserted R33's 16 Fr/10 cc Foley catheter.On 06/11/2026 at 11:50 AM, the LPN reported R33 underwent a 72-hour bladder training beginning on 05/01/2026 but failed voiding trials. The LPN indicated the nurse practitioner (NP) ordered a bladder scan which confirmed urinary retention and ordered straight catheterization. According to the LPN, the NP ordered the LPN to insert an indwelling catheter if retention persisted. The LPN acknowledged inserting a 16 Fr/10cc Foley without obtaining clarification from the NP on what size and balloon amount to use and did not check medical record for any active orders for R33's Foley catheter. 06/11/2026 12:14 PM the LPN acknowledged not following physician's order to use a 30 Fr when the LPN inserted a 16 Fr/10cc catheter on 05/05/2026 and failed to follow documentation requirements with regards to catheter insertion.On 06/11/2026 at 12:26 PM, the admission nurse recounted R33 was admitted with a 30 Fr/20 cc Foley catheter and clarified the nursing admission assessment which documented a 26 Fr catheter was a typographical error. The admission nurse indicated the physician's order for a 30cc/20cc was still an active order and it must be discontinued if a provider ordered a new size and balloon amount.On 06/11/2026 at 12:50 PM, the Director of Nursing (DON) indicated expecting nurses to follow physician orders and obtain clarification from the provider if needed. The DON indicated documentation requirements must be met by every nurse inserting a Foley catheter.The facility's Indwelling Catheter Insertion policy revised August 2022, revealed when inserting a Foley catheter the following must be documented in the resident's medical record: date and time procedure was performed, name and title of individual who performed procedure, assessment data such as urine characteristics, size inserted and balloon amount and how resident tolerated the procedure.

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. A PICC line was observed on the resident's right upper arm (RUA) with dressing which appeared to read 05/08/26. R4 indicated the dressing was changed at the facility two weeks ago.On 06/10/2026 at 10:51 AM, the Registered Nurse (RN) assigned to R4 observed the PICC line dressing and described it to be not looking new but looking old and interpreted the dressing date as 06/08/26. R4 insisted no one changed the dressing two days ago. When asked about flushing, the RN indicated flushing R4's PICC line this morning. R4 indicated the RN did not flush the PICC line this morning.On 06/10/2026 at 11:03 AM, the Infection Preventionist (IP) indicated the dressing date appeared to read 06/08/26 but described the dressing as not appearing to have been changed two days ago. The IP was in the room when R4 verbalized the PICC line was changed two weeks ago and it had not been flushed this morning.On 06/10/2026 at 12:04 PM, the IP indicated after reviewing R4's medical record it could be confirmed there was no documentation of any nurse-physician discussion regarding removal or maintenance of the PICC line after IV antibiotics were completed on 06/04/2026, and no care orders for site assessment and 3) the dressing change was signed off on 06/07/2026 and flushing on 06/10/26 which did not align with the resident's recollection of care. The IP could not speak to the discrepancy between the resident's recollection of PICC line care versus the RN's claim of having flushed the port and documented dressing change in medical record.Resident 45 (R45) was admitted on [DATE] and readmitted on [DATE], with diagnoses including encounter for surgical aftercare following surgery of the digestive system and malignant neoplasm of small intestine. On 06/10/2026 at 9:51 AM, R45 laid in bed appearing weak. A peripheral IV line was observed in left hand with undated transparent dressing. An empty medication bag hung on an IV pole on the left side of the bed with tubing looping around the pole. R45 indicated receiving IV antibiotics for infection of the duodenum. R45 indicated the IV line was inserted in the hospital.The Clinical admission assessment dated [DATE] lacked documented evidence R45 was admitted with a peripheral IV line on left hand.On 06/10/2026 at 9:55 AM, by direct observation and after reviewing medical record the IP confirmed the admitting nurse failed to identify R45's IV line, there was no documentation of a nurse-physician discussion regarding whether to remove or maintain the peripheral line, and no care orders were transcribed and carried out for site assessment and dressing changes. The IP indicated these missteps placed the resident at risk for phlebitis.On 06/11/2026 at 2:02 PM, the Director of Nursing (DON) indicated the admitting nurse was responsible for identifying and documenting presence of IV accesses. According to the DON the nurse should obtain an order for removal unless ordered to maintain the line. If ordered to maintain the line, care orders for flushing, site assessment and dressing changes would be transcribed into medical records. The DON indicated not following policy placed these residents at risk for infection.The facility's Peripheral and Midline Dressing Changes policy dated June 2025, documented to prevent IV-related complications, perform site care and dressing changes every seven days when using a transparent dressing or when damp, loosened or soiled.

Based on observation, interview, and document review, the facility failed to ensure a restroom soap dispenser contained soap for hand hygiene. The deficient practice had the potential to increase the risk of inadequate hand hygiene and the transmission of infectious organisms. Findings include: On 06/10/2026 at 8:00 AM, reception staff identified two restrooms near the facility's front lobby as the only restrooms designated for staff and visitor use on the facility's first floor. Upon entering the double doors leading to the restrooms, the soap dispenser in the restroom located immediately to the left was observed with a clear soap cartridge completely empty of soap. No alternative soap or hand hygiene products were available in the restroom. On 06/10/2026 at 8:04 AM, a Registered Nurse (RN), confirmed the soap dispenser in the bathroom was empty. The RN explained Housekeeping was in charge of changing the soap cartridges in the restrooms and should have provided a new soap cartridge before it ran out. The RN acknowledged soap should have been available in the restroom for hand hygiene to prevent the spread of infection. 06/10/2026 at 2:31PM, the Infection Preventionist (IP), reported Housekeeping had a routine of checking all soap and sanitizer dispensers including restrooms. The IP acknowledged soap should have been available in the restroom at all times. The IP explained the expectation was staff was to report any empty or broken dispensers to maintenance so that soap dispensers may have been filled. The IP acknowledged the availability of soap in restrooms was part of the facility's standard precautions and important to prevent the spread of infection.A facility policy titled Handwashing/Hand Hygiene revised August 2019 documented all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Soap (liquid or bar; anti-microbial or non-antimicrobial) was necessary for hand hygiene. Hand hygiene products and supplies including soap should be readily accessible and convenient for staff to use to encourage compliance with hand hygiene policies.

Based on interview, record review, and document review, the facility failed to ensure a resident's advanced directive was accurately documented in the medical record for 1 of 17 sampled residents (Resident 37). The deficient practice had the potential to result in administration of unwanted life-sustaining treatment against the resident's expressed wishes. Findings include: Resident 37 (R37) R37 was admitted on [DATE], with diagnosis including hydronephrosis with renal and ureteral calculous obstruction, pressure induced deep tissue damage of left heel, and malignant neoplasm of prostate. R37's electronic medical record documented Full Code, medical interventions included full treatment, long term artificial nutrition or feeding tube. A Physician order dated [DATE], documented admit to hospice with primary diagnosis of malignant neoplasm. A Care Plan initiated [DATE], documented R37 was on hospice care. Interventions included to respect resident wishes. A Physician Orders for Life-Sustaining Treatment (POLST) form signed by R37 dated [DATE], documented do not attempt resuscitation, no cardiopulmonary resuscitation (CPR), comfort focused treatment, no artificial nutrition or feeding tube, and R37 had decisional capacity. On [DATE] at 4:19 PM, a Licensed Practical Nurse (LPN), acknowledged R37's electronic medical record listed R37's code status as Full Code. The LPN confirmed the most current POLST form dated [DATE], indicated a Do Not Resuscitate status. The LPN acknowledged the electronic medical record should have been updated to reflect R37's current code status in accordance with the POLST form. The LPN explained the wrong code status in the electronic medical record could have resulted in R37 receiving medical interventions R37 did not want. On [DATE] at 4:35 PM, the Director of Nursing (DON), acknowledged R37's electronic medical record listed R37's code status incorrectly as Full Code. The DON explained R37's code status in the electronic medical record should have been updated when R37 made the change to Do Not Resuscitate on the POLST form dated [DATE]. The DON indicated consequences of a wrong code status in the electronic medical record included providing unwanted medical interventions and not honoring R37's wishes. A facility policy titled Advanced Directives documented the resident had the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The resident's wishes were communicated to the resident's direct care staff by placing the advanced directive documents in a prominent, accessible location in the medical record.

Based on observation, interview, record review, and document review, the facility failed to obtain a physician's order for the insertion of an intravenous (IV) line and for the care and monitoring of the IV site for one of 17 sampled residents (Resident #116). The deficient practice had the potential to significantly increase the resident's risk of serious complications such as bloodstream infection, phlebitis, infiltration, and sepsis.Findings include:Resident #116 (R116)R116 was admitted on [DATE], with diagnoses including acute post-hemorrhagic anemia, acute kidney failure, and venous insufficiency.On 06/24/2025 at 10:48 AM, an intravenous (IV) line was observed in R116's right arm. The IV line had a dressing dated 06/15/2025. R116 verbalized the IV site was painful and stated it had been used for iron administration, which had been completed two days ago. Resident 116 reported informing the nurse to remove the IV; however, it remained in place at the time of observation.Physician order dated 06/14/2025, documented Ferrlecit IV solution 12.5 milligrams per milliliter (mg/ml) to administer 125 mg IV one time a day for iron deficiency anemia for eight administrations. (Ferrlecit was an iron replacement product administered IV to treat iron deficiency anemia).Medication administration record for June 2025, revealed the medication Ferrlecit was administered as ordered from 06/15/2025 to 06/22/2025. On 06/26/2025 at 9:00 AM, the Charge Nurse explained R109 had been receiving IV iron therapy for anemia. The course of medication had been completed on June 22, 2025; however, the physician requested follow-up lab work to confirm acceptable iron levels before authorizing the removal of the IV line.The medical record lacked documented evidence a physician's order was obtained for the insertion of the IV line, as well as for the ongoing care and monitoring of the IV site to reduce potential risks of preventable complications, including infection, phlebitis, or IV-line dislocation.On 06/26/2025 at 11:00 AM, the Charge Nurse confirmed orders for the insertion on the IV line and for the care and monitoring of the IV insertion site were not obtained. The Charge Nurse acknowledged the IV insertion site should have been routinely assessed for signs of infection, bleeding, or dislocation to prevent potential complications, and the assessment documented in the medical record.The facility policy titled Peripheral and Midline IV Catheter Flushing and Locking, last updated in October 2024, revealed staff should document IV care in the treatment administration record. Documentation should include the location of the catheter, the condition of the IV insertion site, and the status of the dressing. The policy also specified that any complications must be recorded and reported to the supervisor and the attending physician.

Based on observation, interview, record review and document review, the facility failed to ensure an air intake cabinet filter was installed in an oxygen concentrator prior to being used for 1 of 17 sampled residents (Resident #102). The deficient practice had the potential to affect the quality of the oxygen delivered, placing the resident at risk for exacerbation of preexisting respiratory conditions or exposing the resident to environment contaminants.Findings included:Resident #102 (R102) R102 was admitted on [DATE], with diagnoses including hypertension, hyperlipidemia, diabetes mellitus type 2, chronic kidney disease, recurrent UTIs, history of obstructive uropathy.A physician order dated June 14, 2025 at 6:00 PM, documented the administration of oxygen at 3 liters per minute via nasal cannula every shift for the treatment of hypoxia.06/25/25 at 11:00 AM, R102 was receiving oxygen via nasal cannula from an oxygen concentrator (a medical device that provides supplemental oxygen). The concentrator did not have installed an air intake cabinet filter (a filter that removes dust and particles from the air, protecting the machine and ensuring the oxygen remains clean).A physician order dated 06/14/2025, documented oxygen tubing and humidifier should be changed at bedtime every Saturday to support management of shortness of breath (SOB). The order did not mention when and how often the air intake cabinet filter should be replaced.On 06/26/2025 at 3:20 PM, the oxygen concentrator was still missing the intake air filter. A Certified Nursing Assistant (CNA) verified this observation and explained the intake filter, humidifier, and tubing were typically replaced weekly by the night shift nursing staff.On 06/26/2025 at 3:40 PM, the Charge Nurse stated the oxygen concentrator should have been equipped with an air intake filter to prevent the resident from being exposed to dust and contaminants. The Charge Nurse acknowledged the absence of this filter posed a potential health risk, as the device may not have delivered adequately purified oxygen to the resident.The oxygen concentrator manufacturer's user manual, dated November 2009, documented a cautionary directive stating the concentrator should not be operated without the filter installed.

Based on record review, interview, and document review, the facility failed to obtain consents for the administration of psychoactive medications, develop a care plan, and monitor target behaviors and side effects related to the administration of psychoactive medications for 1 of 17 sampled residents (Resident #101). The deficient practice had the potential to adversely affect the resident's health, safety, and well-being by failing to identify possible adverse drug reactions, behavioral deterioration, or ineffective treatment. Findings include: Resident #101 (R101) R101 was admitted on [DATE], with diagnoses including metabolic encephalopathy secondary to urinary tract infection, short-term memory loss and cognitive impairment. The Minimum Data Set (MDS) assessment (a standardized, federally mandated tool used in nursing homes and long-term care facilities to evaluate the clinical, functional, and psychosocial status of residents) dated 06/11/2025, revealed a Brief Interview for Mental Status (a short, structured tool used primarily in nursing homes to assess a resident's cognitive function) score of 12, indicating a moderate cognitive impairment. A psychiatric evaluation dated 05/27/2025, documented R101 and the facility's staff reported intermittent periods of depressed mood and agitation. At that point pharmacological interventions were discussed with R101's spouse who deferred the medication for two weeks. The psychiatric evaluation indicated changes in mood and behaviors as well as changes in symptoms of psychosis, depression, anxiety and mania would be continuously monitored. A physician order dated 06/03/2025, documented Mirtazapine 7.5 milligram (mg) by mouth at bedtime for depression. A physician progress note dated 06/05/2025, revealed R101's mentation improved but was experiencing anxiety and irritability. The physician reported the initiation of Hydroxyzine 10 mg twice daily for anxiety management. A physician order dated 06/06/2025, indicated Hydroxyzine 10 mg, twice daily for anxiety management. The medication administration record (MAR) for June 2025, revealed Mirtazapine 7.5 mg was administered as ordered on 06/04/2025 and from 06/06/2025 through 06/24/2025, and Hydroxyzine 10 mg was administered from 06/07/2025 through 06/19/2025. The medical record lacked documentation indicating staff monitored anxiety-related behaviors and potential side effects of Hydroxyzine from 06/07/2025 to 06/18/2025. Additionally, there was no evidence depression-related behaviors, and the side effects of Mirtazapine were monitored from 06/04/2025 to 06/18/2025, during which time R101 was receiving both medications. The medical record revealed the orders to monitor target behaviors related to the administration of Hydroxyzine and Mirtazapine, and side effects of these drugs were not obtained until 06/19/2025. The orders directed staff to monitor and document R101's behaviors each shift for signs of depression and anxiety. The order required staff to record the number of behavioral episodes, the interventions used, and their effectiveness, and to observe for side effects of antidepressant and anti-anxiety medications. Additionally, the medical record revealed the informed consents for the use of Hydroxyzine and Mirtazapine psychoactive medication were not obtained prior to start the administration of these drugs. The medical record lacked documented evidence a care plan was developed and implemented for the use of Mirtazapine and Hydroxyzine when the medications were initially ordered on 06/03/2025 and 06/06/2025 respectively. On 06/25/2025 at 3:00 PM, the Charge Nurse confirmed consents for the administration of Hydroxyzine and Mirtazapine had not been obtained, and behaviors and side effects were not monitored until 06/19/2025. The Charge Nurse acknowledged the importance of developing a care plan and monitoring the behaviors and side effects to ensure effectiveness of the therapeutic efforts. The facility policy titled Psychotropic Medication Use last revised July 2022, documented drugs such as anti-depressants and antianxiety were subject to monitoring, and residents and family members were involved in the medication management process.

Based on observation, record review, interview and document review, the facility failed to ensure an insulin pen was not left unattended in a resident's room and failed to maintain a medication storage room free of expired medication. The deficient practice had the potential to compromise resident safety by exposing the residents to the risk of using expired or improperly stored medications and allowing for possible misuse of unattended insulin pens.Findings included:On [DATE] at 3:20 PM, a Glargine insulin pen containing medication was discovered on the overbed meal table in room [ROOM NUMBER]. A Certified Nursing Assistant (CNA) confirmed the observation and acknowledged the insulin pen had been left unattended, posing a potential safety risk to the resident and others in the unit. On [DATE], at 3:40 PM, the Charge Nurse was notified about the Glargine insulin pen found in room [ROOM NUMBER]. The Charge Nurse confirmed the medication belonged to the resident assigned to room [ROOM NUMBER] (Resident #102) and acknowledged the insulin pen should not have been left unattended, citing it as a potential safety concern. Resident #102 (R102) R102 was admitted on [DATE], with diagnoses including hypertension, hyperlipidemia, diabetes mellitus type 2, chronic kidney disease, recurrent UTIs, history of obstructive uropathy. A physician order dated [DATE], documented Insulin Glargine Solution 100 units per milliliter to be administered to R102 at a dose of 15 units subcutaneously daily at 9:00 AM for the management of diabetes. On [DATE] at 4:50 PM, the nurse who administered the medications to R102 confirmed the insulin Glargine was administered in the morning as ordered and acknowledged had left the insulin pen in the resident's room. On [DATE] at 2:09 PM, the Director of Nursing (DON), explained medications should not be left unattended for resident safety due to the risk of medication misuse and to ensure resident received medication as ordered. Expired Medication:On [DATE] at 12:44 PM, an inspection was conducted on the first-floor medication room with an Admissions Registered Nurse (RN) present. The following medication was found to be expired:Two intravenous (IV) bags labelled Daptomycin 575 milligram (MG)/100 milliliter (ML) Normal Saline (NS), use by date [DATE]. On [DATE] at 12:44 PM, the Admissions RN, confirmed the medication was expired. The Admissions RN acknowledged the two IV bags should have been discarded. The Admissions RN explained the expired medication should have been discarded to avoid confusion with the resident's medication and for resident safety. On [DATE] at 2:09 PM, the Director of Nursing (DON), explained expired medication should have been separated and discarded. The DON confirmed expired medication was not to be kept in the medication storage room.A facility policy titled Medication Labeling and Storage revised February 2023, documented all medications and biologicals should be stored in locked compartments. The policy indicated if the facility had discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy was to be contacted for instructions regrading returning or destroying the items.Complaint #NV00074207

Based on observation, interviews, record review, and document review, the facility failed to ensure staff followed appropriate infection control practices by wearing required personal protective equipment (PPE) while providing care to 1 of 17 sampled residents (Resident 32). The deficient practice had the potential to contribute to the transmission of infections to other residents. Findings include: Resident 32 (R32) R32 was admitted on [DATE], and readmitted [DATE], with diagnosis including acute embolism and thrombosis of right popliteal vein, acute embolism and thrombosis of right tibial vein, and urinary tract infection. A Physician order dated 06/20/2025, documented contact isolation precautions for Extended-Spectrum Beta-Lactamase (ESBL) (an enzyme produced by certain bacteria) Klebsiella Urinary Tract Infection (UTI). On 06/24/2025 at 8:44 AM, a contact precautions sign was observed posted next to R32's room door. The contact precautions sign indicated providers, and staff must wear PPE including a gown before entering the room. On 06/24/2025 at 8:49 AM, a Speech Therapist (ST), was observed in R32's room, standing next to R32's bed, holding a conversation with the resident. The ST was not wearing a gown. The ST acknowledged did not put on a gown prior to entering the room to provide care to R32. The ST confirmed the contact precautions sign indicated a gown was to be donned prior to entering the room. The ST confirmed R32 was under contact precautions and explained the ST did know the reason why. The ST stated should have worn a gown while inside the room to prevent becoming infected and passing on the infection to others. On 06/26/2025 at 4:35 PM, the Director of Nursing (DON), explained staff was to wear required PPE when entering rooms with contact precautions. The DON acknowledged consequences of not wearing required PPE included staff becoming sick and spreading disease. The DON indicated staff was expected to adhere to facility infection control and prevention policies by wearing required PPE. A facility policy titled Isolation - Categories of Transmission-Based Precautions revised September 2022, documented Contact Precautions were implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Staff and visitors wore a disposable gown upon entering the room, removed it before leaving the room and avoided touching potentially contaminated surfaces with clothing after gown was removed.

Based on observation, interview, record review and document review, the facility failed to ensure a self-administration medication assessment, care plan, physician's orders, and a safe storage area was completed for 1 of 3 sampled residents (Resident 3). The deficient practice had a potential for a resident not to be properly evaluated if able to safely self-administer a nasal spray medication. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis. On 01/02/2025 at 8:49 AM, a container of saline nasal spray was on R3's overbed tray table. R3 confirmed self-administered the saline nasal spray for when their nose was dry from the oxygen cannula. R3 indicated the saline nasal spray was on overbed tray table to self-administer as needed. On 01/02/2025 at 9:04 AM, the Licensed Practical Nurse (LPN) confirmed resident had a Saline Nasal spray, and there was no physician's order for the Saline Nasal spray or for R3 to self-administer the saline nasal spray. The medical record lacked documented evidence of the following: -A self-administration assessment -A care plan for self-administration had been completed -A physician's order had been obtained for R3 to self-administer medication -A physician's order for R3 to receive the saline nasal spray On 01/03/2025 at 9:30 AM, a Registered Nurse (RN) confirmed every resident who wanted to self-administer medication would require a self-administration assessment, a care plan, a physician's order to self-administer, a physician's order for the medication, and must be provided a safe area to store the medication. The self-administration assessment ensured the resident was able to administer the medication correctly and safely. On 01/03/2025 at 10:08 AM, the Director of Nursing (DON) reviewed R3's medical record. The DON confirmed the medical record lacked documented evidence of the following: -A self-administration assessment -A care plan for self-administration had been completed -A physician's order had been obtained for R3 to self-administer medication -A physician's order for the R3 to receive the saline nasal spray The Director of Nursing verbalized the resident should not have had the medications in the room or self-administered the Saline Nasal spray. The facility policy titled Resident Self-Administration of Medication revised 02/2021, documented each resident who self-administers medication will have an assessment completed in the medical records, a care plan, and a safe and secure place not accessible by other residents to store the medication. Any medications found at the bedside not authorized for self-administration would be turned over to the nurse in charge and returned to the family or responsible party.

Based on observation, interview, record review and document review, the facility failed to ensure a resident was provided supervision during medication administration for 1 of 3 sampled residents (Resident 3). The deficient practice had the potential to place a resident at risk of an accident. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis. On 01/02/2025 at 8:49 AM, the following was on R3's overbed tray table: - a clear plastic medication cup with one white oval tablet - a clear plastic medication cup of 9 various tablets R3 verbalized the nurse had left the oral medications with the resident to take at 9:00 AM. On 01/02/2025 at 9:04 AM, the Licensed Practical Nurse (LPN) verbalized R3 was given their 9:00 AM medications, and the LPN had stepped out of the resident's room to get something from the medication cart before returning to observe the resident take the medication. The LPN revealed should have stayed with R3 until all the medications had been taken. On 01/03/2025 at 9:30 AM, a Registered Nurse (RN) verbalized during medication pass; the nurse must remain at the resident's side to ensure medication was properly taken according to the physician's orders. The RN explained if the resident was not observed taking the medication, the resident could potentially choke or forget to take the medication. The RN revealed a confused resident could potentially wander into the room and take the medication since it was left unsecured in the resident's room. On 01/03/2025 at 10:08 AM, the Director of Nursing verbalized the LPN should have remained by the resident's side until all medication was taken. The facility policy titled Administering Oral Medications revised on 10/2010, documented the facility procedure for medication administration included remaining with the resident until all medications have been taken.

Based on observation, interview, record review and document review, the facility failed to ensure medications were secured in; 1) 1 of 2 central supply rooms on the first floor which contained wound care supplies and 2) 1 of 3 sampled resident's room (Resident 3). The deficient practice had the potential risk of unauthorized access to medications, medication errors, theft, or misuse of medication within the facility. Findings include: 1. Unsecured Wound care Supplies in a Supply Room On 01/02/2025 at 7:40 AM, the central supply room door was open, the lights were on, and no staff members were in the supply room. The supply room contained wound care supplies. On 01/02/2025 at 8:17 AM, the central supply room door was open, the lights were on and no staff members in the supply room. The following unsecured wound care supplies were located on the shelves in the central supply room: -16-ounce bottles of Dakin's solution (a topical antiseptic) -16-ounce bottles of Hydrogen Peroxide (a topical antiseptic) -Petroleum jelly dressings and other medicated wound care dressings -Spray bottle of wound cleanser On 01/02/2025 at 8:18 AM, the Central Supply Clerk entered the room and stated the central supply rooms were never locked so staff can have access to supplies, including wound care supplies. The Central Supply Clerk confirmed the room should have been locked. On 01/02/2025 in the afternoon, the Administrator acknowledged the supply rooms were left opened. On 01/03/2025 at 9:49 AM, the Transport Coordinator stated their desk was located in the Central Supply room with the wound care supplies. The Transport Coordinator advised the door to the room did not have a lock due to staff constantly going in and out of the supply room to obtain needed supplies. The central supply room was supposed to remain open even if the Transport Coordinator or the Central Supply Clerk were not present. The Transport Coordinator verbalized the facility just installed a lock on the door during the night and guidance was given to lock the central supply room door moving forward. On 01/03/2025 at 10:23 AM, the Director of Nursing confirmed the Central Supply room should have been locked because it contained wound care medications. 2. Unsecured Medication in a Resident Room Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis. On 01/02/2025 at 8:49 AM, the following was on R3's overbed tray table: - a container of Saline Nasal spray - a clear plastic medication cup with one white oval tablet - a clear plastic medication cup of 9 various tablets The following over the counter medications were on a storage rack in the resident's bathroom and contained the following: - a tube of topical analgesic cream - three 15 milliliter containers of lubricant eye drops On 01/02/2025 at 9:04 AM, the Licensed Practical Nurse (LPN) revealed were not aware the resident had the above medications in R3's bathroom storage rack. The LPN acknowledged the saline nasal spray was left unsecured on the resident's bedside tray table. On 01/03/2025 at 9:30 AM, a Registered Nurse (RN) stated medication should never be left out, as it was considered unsecured. The RN stated it was dangerous not only for the resident, but another confused resident could potentially wander into the room and take the medication. The facility policy titled Medication Labeling and Storage revised on 02/2023, documented all medications and biologicals, including antiseptics and disinfectants, must be stored in locked compartments with only authorized personnel having access to keys.

Based on interview, record review and document review, the facility failed to ensure the resident and/or resident's family were informed about the resident being placed on isolation (transmission-based precautions) upon admission for 1 of 15 sampled residents (Resident 46). The deficient practice had the potential for the facility not respecting the rights of the resident to be fully informed about their treatment. Findings include: Resident 46 (R46) R46 was admitted on [DATE], with diagnoses including epilepsy and abnormal findings of blood chemistry. On 07/09/2024 at 12:17 PM, R46's family member indicated nobody explained to the resident and resident's family about R46 being on isolation upon admission. The family member revealed nobody from the facility explained why the resident was on isolation. The family member confirmed R46 had tested negative for COVID-19. R46's Face Sheet (demographics) documented the family member was the resident's emergency contact and next of kin. R46's medical record lacked documented evidence the resident and/or resident's family was notified about the resident being placed on isolation upon admission. On 07/10/2024 at 12:56 PM, the Infection Preventionist (IP) Nurse confirmed the findings and revealed R46 was admitted on [DATE] at night and was placed on isolation upon admission due to loose stools. The IP Nurse indicated R46 had tested negative for COVID-19. The IP Nurse explained the nurses were expected to notify the resident or resident's family/responsible party (RP) if isolation was warranted. During admission, the charge nurse or admitting nurse was responsible to inform the resident or resident's family/RP in real time and document such notification in the progress notes. The IP Nurse revealed R46 was placed on contact/droplet precautions (transmission-based precautions) upon admission on 06/17/2024 and the isolation was discontinued on 06/19/2024. The IP Nurse provided the line listing form (infection surveillance) which corroborated the interview. The IP Nurse confirmed the Progress Notes dated 06/19/2024 (when the isolation was discontinued), documented the Admission Nurse explained to R46 and resident's family member about the contact/droplet precautions. The IP Nurse acknowledged the notification should have been done on 06/17/2024 upon R46's admission and when the resident was placed on isolation. On 07/10/2024 at 2:31 PM, R46 was sitting in a wheelchair inside the resident's room. R46 indicated being placed on isolation upon admission but nobody explained the reason for the isolation. R46 revealed being scared when people were coming inside the room wearing a gown and with mask and gloves on. The resident was told there was an isolation sign by the door. R46 indicated coming from the hospital prior to admission and the resident was aware of having no infection and negative for COVID-19. On 07/10/2024 at 2:34 PM, the Admission Nurse indicated would have informed the resident or the resident's family within the shift when a resident was placed on isolation upon admission. The Admission Nurse explained the notification would have been documented in the progress notes. On 07/11/2024 at 8:02 AM, the Director of Nursing (DON) indicated the nurse who determined to put a resident on isolation should have informed the resident about the reason for the isolation and the necessary precautions to be taken. The notification should have been done in real time or when it was determined the resident needed to be on isolation. Either the admission nurse, charge nurse, medication nurse, or nursing management could have talked to the resident as long as they were the one who determined the resident should be placed on isolation. The facility's policy titled Resident Rights dated February 2021, documented the residents had the right to be notified of their medical condition and of any changes in their condition. The residents had the right be informed of and participate in their care planning and treatment.

Based on interview, record review, and document review, the facility failed to follow the resident's choice for comfort-focused treatment for 1 of 3 sampled closed records (Resident 159). The failed practice resulted in a non-emergent hospital transfer which potentially caused the resident discomfort and distress. Findings include: Resident 159 (R159) R159 was admitted on [DATE], with diagnoses including malignant neoplasm of lungs and cachexia (wasting syndrome). A Provider Order for Life-Sustaining Treatment (POLST) dated 07/02/2024, documented in the event of a cardiopulmonary arrest, R159 elected not be resuscitated (DNR), allow natural death. The document revealed R159 desired comfort-focused treatment with a goal of maximizing comfort through symptom management. Transfer to hospital only if comfort needs cannot be met in current location. A physician's order (undated), documented do not transfer R159 to acute hospital per family member request. A nursing progress note dated 07/04/2023, revealed a certified nursing assistant (CNA) found R159 unresponsive at 7:00 PM and notified the nurse. The nurse assessed R159 who was found to have a blood pressure (BP) of 110 millimeters of mercury mmHg/52 mmHg, heart rate (HR) of 83, Oxygen saturation (O2Sat) of 94% on two liter of Oxygen via nasal cannula and temperature of 98.4 degrees Fahrenheit. Charge nurse was notified, 911 called. Paramedics arrived at 7:10 PM and left with R159 at 7:30 PM. Physician and family member made aware of the situation. A nursing progress note dated 07/04/2023, documented an emergency department nurse called to inform the facility R159 was going to be transported back to the facility. R159's family member arrived at the hospital, spoke with physician and no interventions were done due to R159's DNR status. A nursing progress note dated 07/04/2023, documented R159 arrived at facility at 10:46 PM with transport staff and a family member. Resident still unresponsive. A provider progress soap note dated 07/05/2024, revealed R159's family member was very upset due to the facility transferring R159 to the hospital on 07/04/2024 due to unresponsiveness. R159 was sent to the hospital where no interventions were done and was sent back to the facility. R159's family member emphasized to the nurse practitioner (NP) R159 was a DNR and wanted comfort measures only and no aggressive treatment. R159's family member agreed to a hospice evaluation. A hospice nurse came to evaluate R159 on 07/05/2023. A nursing progress note dated 07/05/2023, revealed R159 was pronounced at 8:29 PM. NP and family member notified. Coroner approved release of body to mortuary. On 07/10/2024 at 10:45 AM, the NP reviewed R159's POLST and indicated if R159 was found unresponsive, with stable vital signs and there were no signs and symptoms of discomfort or distress, the NP would have told the nurse to contact the family member who should make the decision on whether to transfer the resident to the hospital. The NP reviewed R159's medical record and indicated it appeared the Registered Nurse (RN) seemed to have called 911, transferred R159 to the hospital and notified the NP and the family member after the fact. The NP emphasized residents who elected DNR on their POLST may still be sent out to the hospital if they were in acute distress such as unrelieved pain, respiratory distress, or bleeding but if R159 was not showing signs of distress and was just unresponsive, the NP repeated the RN would have been instructed to ask the family member to decide as long as the RN notified the NP first. On 07/10/2024 at 2:27 PM, the RN who was assigned to R159 on the night of the incident recalled being notified by a CNA regarding R159 being found unresponsive. The RN went inside the room and assessed R159 who was found to be unresponsive with stable vital signs and no signs of discomfort. The RN indicated not checking R159's code status but assumed the charge nurse who was notified of the incident may have confirmed R159's code status. The RN indicated it was difficult to recall the sequence of events but based on the RN's documentation, the RN indicated being the one to call 911, and contacting the NP and R159's family member after the resident had already left. The RN recalled R159's family member was very upset upon learning R159 was transferred to the hospital and told the nurse R159 should not be sent to the hospital unless the resident was in actual distress. The RN emphasized R159 was not in any distress or discomfort during this time but was merely unresponsive. On 07/10/2024 at 2:52 PM, the charge RN who was on duty on the night of the incident indicated not being able to recall whether the RN notified the charge RN regarding R159's condition, or asked the charge RN to confirm R159's code status. The charge nurse indicated expecting the RN to assess the resident and when the resident was assessed to be unresponsive with stable vital signs and not in acute distress, the correct thing to do next would be for the RN to call the provider. The charge nurse indicated nurses can transfer residents to the hospital prior to physician notification only in emergent situations such as hypoxia, traumatic injury, bleeding episodes, etc. R159's situation was not considered emergent and so the physician should have been notified first before the transfer to the hospital. On 07/10/2024 at 2:55 PM, the Director of Nursing (DON) indicated when the RN assessed R159 to be unresponsive with stable vital signs, the RN should have confirmed the resident's code status and contact the physician once all pertinent information has been gathered. The DON indicated based on the RN's documentation, it appeared the RN called 911 and sent R159 to the hospital prior to notifying the physician. The DON stated because the RN did not notify the NP prior to R159's hospital transfer, there may have been missed opportunity in involving the resident's family member in the decision-making process to ensure the resident's treatment wishes were honored. The Change in Condition policy revised February 2021, documented the facility would promptly notify the resident, the attending physician, and the resident representative of changes in the resident's condition or status. Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider including information prompted by the SBAR (situation, background, assessment, recommendation) communication form. The Advanced Directives policy revised September 2022, documented the physician order for life-sustaining treatment (POLST) recorded a resident's treatment wishes and were communicated to direct care staff and physician by placing the document in a prominent, accessible location. Facility staff were not required to provide care which conflicts with the resident's advanced directives. Complaint #NV00069770

Based on observation, interview and record review, the facility failed to ensure a physician's order for an indwelling urinary catheter (Foley catheter) included the medical justification and the physician's orders were obtained to include all components of a Foley catheter care for 1 of 15 sampled residents (Resident 26). The deficient practice had the potential for the resident to acquire infection and unnecessary use of a Foley catheter. Findings include: Resident 26 (R26) R26 was admitted on [DATE], with diagnoses including aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and functional quadriplegia. On 07/09/2024 at 9:25 AM, R26 was lying in bed and was observed to have an indwelling urinary catheter in place. The physician's orders dated 06/15/2024, included the following: - Urinary Catheter: 16 French (catheter size) 10 bulb indwelling catheter - Urinary Catheter Care: Cleanse with soap and water every shift. Empty Foley bag every shift for urinary retention. R26's medical record lacked documented evidence of a physician's order which included the medical justification for the use of the Foley catheter and physician's orders were obtained on when to change the Foley catheter and the urinary catheter bag. On 07/11/2024 at 2:22 PM, the Infection Preventionist (IP) Nurse explained the nurses were expected to obtain physician's orders for the Foley catheter use with a medical diagnosis (justification) to support the use of the Foley catheter, for monitoring the output, and for changing the Foley catheter as needed (PRN) or when clogged. The IP Nurse confirmed there was no medical diagnosis written in the physician's order for R26's Foley catheter. The IP Nurse indicated the need to check the order set for Foley catheter care and the facility's policy. On 07/11/2024 at 2:33 PM, a Registered Nurse (RN) revealed the nurses should have obtained the physician's orders for Foley catheter use which included the size of the Foley and the medical justification for the use of Foley such as urinary retention. The RN indicated the physician's orders for Foley catheter care should have been obtained which included to clean with soap and water every shift, empty Foley bag every shift, monitor and document output every shift, change the Foley bag every month and PRN, and change Foley catheter PRN. On 07/11/2024 at 2:43 PM, the IP Nurse explained the order set for Foley catheter care included to change the Foley catheter and the urinary drainage bag PRN. The IP Nurse indicated the physician's order should have included the medical diagnosis to support the use of the Foley catheter. The IP Nurse confirmed there were no physician's orders obtained to change the urinary drainage bag and the Foley catheter as needed for R26.

Based on observation, interview, record review and document review, the facility failed to ensure a physician's order was obtained for an insertion of a peripheral intravenous (IV) access and care orders were entered and documented for the IV access for 1 of 15 sampled residents (Resident 161). The deficient practice placed the resident at risk for phlebitis (site infection). Findings include: Resident # 161 was admitted on [DATE], with diagnoses including right femur fracture with routine healing. On 07/09/2024 at 10:18 AM, R161 was seated in wheelchair watching television. A single lumen peripheral IV access was observed in R161's left forearm. The IV insertion site was covered with transparent dressing with white paper tape on each side. The dressing was not signed and dated and red drainage was observed around the insertion site. An IV pump was observed on the left side of the resident's bed. On 07/09/2024 at 10:20 AM, R161 indicated sustaining a fall-related fracture which required surgery and R161 was receiving antibiotics to prevent an infection since the surgical site still had drainage. R161 indicated the IV access was inserted at this facility a few days ago for IV antibiotic administration. A physician's order dated 07/03/2024, documented to give Cefepime hydrochloride IV solution two grams per 100 milliliter solution every 12 hours for right hip surgical drainage for seven days from 07/03/2024 until 07/10/2024. The medical record lacked documented evidence a physician's order to insert a peripheral IV access and care orders were entered and carried out for the IV access such as site monitoring and flushing. On 07/09/2024 at 10:29 AM, a Licensed Practical Nurse (LPN 1) confirmed by direct observation R161's IV access was unsigned, undated and had bloody drainage around the insertion site. The LPN indicated the facility policy was for peripheral lines to be replaced every 72 hours, so it was important to know when the peripheral line was inserted. On 07/11/2024 at 7:42 AM, LPN 2 indicated being assigned to R161 on 07/03/2024 but the LPN indicated not being the nurse who inserted R161's IV access and the line may have been inserted by night shift. LPN 2 explained a peripheral IV insertion required a physician's order and the nurse who inserted the IV access was responsible for entering care orders such as flushing and site monitoring every shift and replace every 72 hours or as needed when soiled, leaking and loose dressing. LPN 2 reviewed R161's medical record and confirmed there was no documentation a physician's order was obtained to insert an IV line and there were no care orders such as site monitoring and flushing every shift and remove and replace the IV access every 72 hours or as needed. On 07/11/2024 at 9:00 AM, the Director of Nursing (DON) indicated a physician's order was required for insertion of a peripheral line. According to the DON, the nurse who inserted the IV access was responsible for entering care orders such as site monitoring and flushing every shift. The DON stated the facility protocol was for nurses to sign and date all IV dressings so other nurses may know when the peripheral line was due to be replaced since peripheral IVs were meant for short term use and should be replaced every 72 hours. The DON reviewed R161's medical record and confirmed there were no orders to place R161's IV access and there were no care orders such as flushing, site assessment and replacing every 72 hours and as needed. The DON indicated consequences to not following the facility policy on IV site care was potential infection. The Peripheral IV Catheter Insertion policy revised February 2022, documented a physician's order was necessary for this procedure. Once inserted, label the dressing with date and initials.

Based on observations, interviews, record review, and document review, the facility failed to ensure the medication error rate was below five (5) percent (%) when three errors were identified with 40 opportunities observed, calculating an error rate of 7.5 %. The deficient practice posed a potential risk of injury or harm to the resident. Findings include: The facility policy titled Administering Medications (2001) documented medications were administered in accordance with prescriber orders. The individual administering the medication would check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. On 07/10/2024 in the morning, a medication administration pass observation was performed with 40 opportunities observed and revealed three errors. The medication error rate was 7.5%. Resident 46 (R46) R46 was admitted on [DATE] with diagnoses including epilepsy, hyperlipidemia, and osteoporosis. 1. On 07/10/2024 in the morning, during the medication administration pass observation, a Registered Nurse (RN1) administered medications to R46 including Psyllium Husk Powder (Metamucil). RN1 used small plastic teaspoon to scoop powder into a five-ounce cup and filled with water and mixed. 2. RN1 appeared to be ready to take medications to R46 and the surveyor questioned the amount of liquid mixed with the powder. RN1 revealed thinking the cup being used was eight ounces and transferred medication to larger cup and mixed in an additional three ounces of water. A physician order dated 06/26/2024 documented Psyllium Husk Powder give one tablespoon by mouth one time a day for bowel management. The product information label documented to mix powder with eight ounces of liquid. RN1 indicated all medications and supplements require a physician order and should be followed along with the product information label for powder mixtures. On 07/11/24 at 8:05 AM, the Director of Nursing (DON) indicated when administering medication or supplements which require mixing with water staff should follow the product guidelines unless a physician order specifies a different amount of water. Resident 4 (R4) R4 was admitted on [DATE] with diagnoses including legal blindness and hypertension. 3. On 07/10/2024 in the morning, during medication administration pass observation, a Registered Nurse (RN2) administered R4's medication including PreserVision AREDS 2, giving R4 two capsules. A physician order dated 08/29/2023 documented PreserVision AREDS 2 oral capsule, give one capsule by mouth one time a day for eye supplement. On 07/10/2024 at 2:34 PM, RN2 revealed thinking RN2 only gave one pill however all medications should be given based on physician orders and would need to be clarified if given outside of the orders and any errors documented. On 07/11/2024 in the afternoon the Assistant Director of Nursing and Director of Staff Development indicated all medications should have a physician order and nursing staff were expected to follow order or clarify medication order as needed.

Based on observation, interview and document review, the facility failed to maintain sanitary condition in the kitchen and failed to ensure 1 of 2 refrigerated juice dispensers was holding the juice cold in the storage chamber. The deficient practice could potentially result to cross-contamination in food preparation and posed a potential risk to safety and health standards. Findings include: Unsanitary condition in the kitchen On 07/09/2024 at 8:48 AM, the following were observed during the initial tour of the kitchen: - The cook's line ventilation hood filters were heavily soiled with gross build-up above the grill. - There was grease build-up on the underside of the griddle. - There was dust build-up in the crevices of the range (stove). The Director of Dining Services was present during the observations and acknowledged the surfaces and equipment in the kitchen should have been maintained in a sanitary condition. The Director of Dining Services explained the kitchen staff were responsible in cleaning the surfaces and equipment in the kitchen. The facility's policy titled Area and Equipment Cleaning revised in January 2023, documented the Maintenance Department was scheduled to clean equipment which required special training and equipment such as the ice maker, refrigeration coils and exhaust hood. Written procedures were available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department. Juice Dispenser On 07/09/2024 at 8:57 AM, the refrigerated juice dispenser (juice machine) in the second floor satellite kitchen, was not holding the juice cold in the storage chamber. Juice was dispensed at 69.2 degrees Fahrenheit. The Director of Dining Services confirmed the observation and acknowledged the temperature of the juice dispensed from the machine should have been in the 40's (degrees Fahrenheit). The Director of Dining Services explained the juice dispenser should have been repaired. On 07/11/2024 at 12:33 PM, the Director of Dining Services confirmed the best quality of the juice dispensed in the juice machine should have been at a temperature of 45 degrees Fahrenheit and below. The facility's policy titled Equipment Maintenance Program revised in January 2023, documented the Director of Food and Nutrition Services, jointly with the Maintenance Department, would plan in writing a program of preventive maintenance for all Food/Nutrition equipment requiring regular maintenance. The program included the regular inspection/maintenance by the Maintenance Department, and periodic servicing by service companies contracted through the Maintenance Department.