Las Ventanas Retirement Comm SNF

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.