Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Las Ventanas Retirement Comm Snf during CMS and state inspections, most recent first.
A resident self-administered a saline nasal spray without a physician's order or a self-administration assessment. The facility failed to document a care plan or provide a safe storage area for the medication, as confirmed by the LPN, RN, and DON. The facility's policy requires an assessment, care plan, and secure storage for self-administered medications.
A resident with anxiety disorder, COPD, and osteoporosis was left unattended with medications, contrary to facility policy. An LPN left the room during medication administration, intending to return, but acknowledged the need to stay with the resident. An RN and the Director of Nursing confirmed the requirement for nurses to remain with residents during medication intake to prevent risks such as choking or medication errors.
The facility failed to secure medications in a central supply room and a resident's room, leading to potential unauthorized access. The supply room was found open with unsecured wound care supplies, and a resident's room contained unsecured medications on the tray table and bathroom rack. Staff confirmed the rooms were typically left unlocked, contrary to facility policy requiring locked storage for medications.
A resident was placed on isolation upon admission due to loose stools, but neither the resident nor their family was informed about the isolation or its reasons. The facility's policy requires that residents be informed of their medical condition and any changes, but this was not followed, as confirmed by the IP Nurse and DON.
A resident with a DNR status and preference for comfort-focused care was transferred to the hospital without prior notification to the physician or family, despite stable vital signs and no distress. The facility failed to adhere to policies requiring confirmation of code status and involvement of family in decision-making.
A facility failed to obtain a physician's order with medical justification and comprehensive care instructions for a resident's Foley catheter. The resident, with conditions including aphasia and functional quadriplegia, had a catheter in place without documented orders for its use or care, such as when to change the catheter and bag. Interviews confirmed the lack of adherence to facility protocols, potentially increasing infection risk.
A resident with a femur fracture and surgical site drainage was observed with an IV access lacking a physician's order and care documentation. The IV site was not signed or dated, and there was red drainage present. LPNs and the DON confirmed the absence of necessary documentation and orders, which are required by facility policy to prevent infection.
The facility's medication error rate was 7.5%, exceeding the acceptable threshold of 5%. Errors included incorrect liquid measurement for a resident's Psyllium Husk Powder and administering two capsules of PreserVision AREDS 2 instead of one. These errors indicate a failure to follow physician orders and product guidelines.
The facility failed to maintain sanitary conditions in the kitchen, with soiled ventilation hood filters, grease build-up, and dust accumulation. Additionally, a juice dispenser was found dispensing juice at an incorrect temperature, indicating a lapse in equipment maintenance. The Director of Dining Services acknowledged these issues, which were contrary to the facility's cleaning and maintenance policies.
Failure to Ensure Proper Self-Administration Procedures for Medication
Penalty
Summary
The facility failed to ensure that a self-administration medication assessment, care plan, physician's orders, and a safe storage area were completed for a resident who self-administered a saline nasal spray. The resident, who had been admitted with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis, was observed with a container of saline nasal spray on their overbed tray table. The resident confirmed they self-administered the nasal spray as needed for dryness caused by an oxygen cannula. However, there was no physician's order for the nasal spray or for the resident to self-administer it. The medical record for the resident lacked documented evidence of a self-administration assessment, a care plan for self-administration, and a physician's order for both the medication and the self-administration. The LPN and RN confirmed these omissions, and the Director of Nursing verified the absence of necessary documentation in the medical record. According to the facility's policy, each resident who self-administers medication should have an assessment, a care plan, and a secure storage area for the medication. The policy also states that unauthorized medications found at the bedside should be turned over to the nurse in charge.
Inadequate Supervision During Medication Administration
Penalty
Summary
The facility failed to provide adequate supervision during medication administration for one resident, identified as Resident 3 (R3). R3, who was admitted with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis, was left unattended with their medications. On the morning of January 2, 2025, R3 had a clear plastic medication cup with one white oval tablet and another cup with nine various tablets on their overbed tray table. R3 indicated that the nurse had left the medications for them to take at 9:00 AM. The Licensed Practical Nurse (LPN) admitted to leaving R3's room to retrieve something from the medication cart, intending to return to observe the medication intake. However, the LPN acknowledged that they should have stayed with R3 until all medications were taken. A Registered Nurse (RN) confirmed that during medication pass, nurses must remain with residents to ensure proper medication intake according to physician orders. The RN highlighted the risk of choking or forgetting to take the medication if not observed, and the potential for a confused resident to access unsecured medications. The Director of Nursing also confirmed that the LPN should have remained with R3 until all medications were taken, as per the facility's policy on administering oral medications.
Unsecured Medications in Supply Room and Resident Room
Penalty
Summary
The facility failed to secure medications in one of the central supply rooms on the first floor and in a resident's room, leading to potential unauthorized access to medications. On two separate occasions, the central supply room door was found open with no staff present, and unsecured wound care supplies, including Dakin's solution, hydrogen peroxide, and medicated dressings, were observed on the shelves. The Central Supply Clerk and the Transport Coordinator confirmed that the room was typically left unlocked to allow staff access to supplies, despite the presence of wound care medications that should have been secured. In a resident's room, unsecured medications were found on the overbed tray table and in the bathroom storage rack. The items included a saline nasal spray, a medication cup with tablets, a tube of topical analgesic cream, and containers of lubricant eye drops. The LPN was unaware of these unsecured medications, and the RN acknowledged the danger of leaving medications unsecured, as it could pose a risk to the resident and others. The facility's policy requires all medications and biologicals to be stored in locked compartments, which was not adhered to in these instances.
Failure to Inform Resident and Family About Isolation
Penalty
Summary
The facility failed to inform a resident and their family about the resident being placed on isolation upon admission. The resident, who was admitted with diagnoses including epilepsy and abnormal blood chemistry findings, was placed on isolation due to loose stools, despite testing negative for COVID-19. The family member, who was the emergency contact and next of kin, reported that no explanation was provided regarding the isolation. The medical record lacked documentation of any notification to the resident or family about the isolation. The Infection Preventionist (IP) Nurse confirmed that the resident was placed on contact/droplet precautions upon admission and that the notification should have been documented in the progress notes. The IP Nurse and the Director of Nursing (DON) both indicated that the nurse responsible for placing a resident on isolation should inform the resident or their family in real time. However, the notification was only documented after the isolation was discontinued. The facility's policy on Resident Rights states that residents have the right to be informed of their medical condition and any changes, which was not adhered to in this case.
Failure to Honor Resident's Comfort-Focused Treatment Preference
Penalty
Summary
The facility failed to honor a resident's choice for comfort-focused treatment, resulting in a non-emergent hospital transfer. The resident, who had a diagnosis of malignant neoplasm of the lungs and cachexia, had a Provider Order for Life-Sustaining Treatment (POLST) indicating a Do Not Resuscitate (DNR) status and a preference for comfort-focused care. Despite this, the resident was transferred to the hospital after being found unresponsive, with stable vital signs and no signs of distress, without prior notification to the physician or family member. The incident occurred when a certified nursing assistant found the resident unresponsive and notified the nurse, who assessed the resident and called 911. The nurse did not check the resident's code status or consult the family member before the transfer. The resident was sent to the hospital, where no interventions were performed due to the DNR status, and was subsequently returned to the facility. The family member expressed upset over the transfer, emphasizing the resident's wish for comfort measures only. Interviews with the nurse practitioner, registered nurse, charge nurse, and Director of Nursing revealed a lack of adherence to the facility's policies regarding changes in condition and advanced directives. The registered nurse failed to confirm the resident's code status and did not notify the physician before the hospital transfer, missing an opportunity to involve the family in the decision-making process. The facility's policies required prompt notification of the physician and family in such situations, which was not followed in this case.
Deficiency in Foley Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure that a physician's order for an indwelling urinary catheter for a resident included the necessary medical justification and comprehensive care instructions. The resident, who was admitted with diagnoses including aphasia following cerebral infarction and functional quadriplegia, was observed with a Foley catheter in place. However, the medical record lacked documentation of a physician's order specifying the medical justification for the catheter's use, as well as detailed instructions for catheter care, such as when to change the catheter and the urinary drainage bag. Interviews with the Infection Preventionist Nurse and a Registered Nurse revealed that the facility's protocol required obtaining physician's orders that included the medical diagnosis justifying the catheter's use, monitoring output, and instructions for changing the catheter and bag as needed. The absence of these orders was confirmed by the Infection Preventionist Nurse, indicating a deficiency in adhering to the facility's policy and potentially increasing the risk of infection and unnecessary catheter use for the resident.
Failure to Obtain Physician's Order for IV Insertion
Penalty
Summary
The facility failed to ensure a physician's order was obtained for the insertion of a peripheral intravenous (IV) access and that care orders were documented for the IV access for one resident. The resident, who was admitted with a right femur fracture and required IV antibiotics for surgical site drainage, was observed with an IV access in the left forearm. The IV site was not signed or dated, and there was red drainage around the insertion site. The medical record lacked evidence of a physician's order for the IV insertion and care orders for site monitoring and flushing. Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed the absence of necessary documentation and orders. The facility's policy required a physician's order for IV insertion and mandated that the nurse who inserted the IV was responsible for entering care orders, including site monitoring and flushing every shift. The policy also required IV dressings to be signed and dated to ensure timely replacement every 72 hours. The failure to follow these protocols placed the resident at risk for infection.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.5% during a medication administration pass observation. This was identified through three errors out of 40 opportunities. The errors involved incorrect administration of medications to two residents. One resident, diagnosed with epilepsy, hyperlipidemia, and osteoporosis, was given Psyllium Husk Powder mixed with an incorrect amount of liquid. The Registered Nurse (RN) initially used a five-ounce cup instead of the required eight ounces, as per the product information label, before correcting the mistake after being questioned by the surveyor. Another resident, with diagnoses including legal blindness and hypertension, was administered two capsules of PreserVision AREDS 2 instead of the prescribed one capsule. The RN responsible for this administration mistakenly believed only one capsule was given. Both incidents highlight a failure to adhere to physician orders and product guidelines, which are critical for ensuring the safe administration of medications.
Sanitation and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure proper temperature control of a refrigerated juice dispenser. During an initial tour of the kitchen, it was observed that the cook's line ventilation hood filters were heavily soiled with a gross build-up above the grill, there was grease build-up on the underside of the griddle, and dust build-up in the crevices of the range. The Director of Dining Services acknowledged these unsanitary conditions and stated that the kitchen staff were responsible for cleaning the surfaces and equipment. The facility's policy indicated that the Maintenance Department was scheduled to clean equipment requiring special training, such as the exhaust hood, but the observed conditions suggested a lapse in adherence to these procedures. Additionally, a refrigerated juice dispenser in the second-floor satellite kitchen was found to be dispensing juice at 69.2 degrees Fahrenheit, which is above the recommended temperature range. The Director of Dining Services confirmed that the juice should have been dispensed at a temperature in the 40s (degrees Fahrenheit) and acknowledged that the juice dispenser should have been repaired. The facility's policy on Equipment Maintenance Program required a written plan for preventive maintenance of all Food/Nutrition equipment, including regular inspections by the Maintenance Department and periodic servicing by contracted service companies. The failure to maintain the juice dispenser at the correct temperature indicated a deficiency in the implementation of this maintenance program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Las Vegas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights Of Summerlin, Llc | 0.1 mi | ★★★★★ | 21 | 0 |
| Neurorestorative | 3.3 mi | ★★★★★ | 16 | 0 |
| Royal Springs Healthcare And Rehab | 4.2 mi | ★★★★★ | 22 | 0 |
| Silver Ridge Healthcare Center | 5 mi | ★★★★★ | 14 | 0 |
| Torrey Pines Post Acute And Rehabilitation | 5 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.