Nursing Center at La Posada, The

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 40 of 40 facility residents. The findings included: 1. During the initial observation tour of the main kitchen on 10/27/24 at 9:00 AM and accompanied with the facility's Food Service Director (FSD), the following were observed: (a) Observation of the main hallway leading up to the kitchen entry/exit door noted that the exterior of the air-conditioning vent was covered with a black mold type substance. It was discussed with the FSD that the mold could result in food borne illness and required cleaning and sanitizing immediately. Photographic Evidence Obtained. (b) Observation of the produce walk-in refrigerator #1 noted that the exteriors of the 3 fan motor covers were rust laden. The surveyor discussed with the FSD the potential for rust substances to fall into foods and result in food contamination. Photographic Evidence Obtained. (c) Observation of walk-in refrigerator #2 noted that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents with a well-balanced diet that meets daily nutritional needs that potentially included 40 of the facility 40 residents, and specifically 6 of 6 sampled residents, Residents #5, #14, #17, #25, 195, and #197, with physician ordered Pureed and Mechanical Soft Diets. The findings included: 1. During the review of Cycle Menu #2 which was being utilized during the survey of 10/27/24, it was noted that the cycle menu documented that the breakfast was the only meal that documented an 8-ounce portion of Choice of Milk. Further review of the lunch and dinner meals noted no milk serving documented and stated only 8-ounce beverage. During an interview with the Certified Dietary Manager (CDM) and Food Service Director (FSD), it was discussed that the requirements set by the government standards for development a nutritious diet for adult 55 years of greater was a minimum 16-ounces of milk or equivalent be served per day. The CDM and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure the Binding Arbitration Agreements was complied with all the regulatory requirements, that included the Agreement must explicitly grant the resident / representative the right to rescind within 30 days of signing it. This affected 35 residents who had signed the facility's current arbitration agreement for the period of 02/02/21 through 10/24/24. The census at the time of survey was 40 residents. The findings included: On 10/27/24 at 10:58 AM, during entrance conference with the Administrator, she verified that there were residents that have entered into an arbitration agreement. She stated this is done when the residents are admitted and part of their admission packet. She confirmed that no residents at this time have resolved a dispute using arbitration. On 10/28/24 at 12:46 PM, an interview was conducted with the Administrator and the admission Director who was responsible for explaining the arbitration agreement to the residents or responsible party. A review of the list of residents or responsible parties who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure the Binding Arbitration Agreements was complied with all regulatory requirements, that included the arbitration proceedings shall take place in a venue that is convenient for both parties. This affected 35 residents who signed the facility's current arbitration agreement for the period of 02/02/21 through 10/24/24. The census at the time of survey was 40 residents. The findings included: On 10/27/24 at 10:58 AM, during entrance conference with the Administrator, she verified that there were residents that have entered into an arbitration agreement. She stated this is done when they are admitted and is part of their admission packet. She confirmed that no residents at this time have resolved a dispute using arbitration. On 10/28/24 at 12:46 PM, an interview was conducted with the Administrator and the admission Director who was responsible for explaining the arbitration agreement to the residents or responsible party. A review of the list of residents or responsible parties who signed the Voluntary Arbitration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to care and services, as evidenced by lack of supervision and assistance, during meals for 1 of 4 sampled residents, Resident #17, reviewed for nutrition. The findings included: Review of the clinical record of Resident #17 revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Fracture of Left Shoulder, Congestive Heart Failure (CHF), Repeated falls, and Psychosis. Review of the current Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment, and the resident required supervision and touching assistance with eating of meals. Review of the current physician orders dated 10/17/24 documented for a Mechanical Soft / No Added Salt Diet. Review of the current care plan dated 10/18/24 documented the following problems: -Impaired Vision - no documented intervention for staff supervision and assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the approved menu was not followed for 2 of 2 sampled residents, Residents #5, and #195, with physician ordered Pureed diets. The findings included: 1. During the review of the approved menu for the lunch meal of 10/27/24, it was documented that the Pureed Diet was to receive 2 Pureed Pancake with 1 ounce of sour cream and 1 ounce of pureed bread. During the observation of the lunch meal on 10/27/24 at 11:45 AM in the second floor satellite serving kitchen, it was noted that the pureed pancakes and pureed bread were not prepared or served. No lunch alternatives were noted to be prepared. Interview with the Food Service Director (FSD) at the time of observation noted that the breakfast / lunch cook failed to review the Pureed menu to ensure that all foods included on the approved pureed menu (pureed potato pancakes and bread) for the lunch meal of 10/27/24 were prepared and served. Review of the facility's diet census for 10/27/24 noted that there were 2 facility residents with physician ordered Pureed diets that included Resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and interviews, the facility failed to monitor daily weights and report a significant weight gain of 9.6 lbs. in one day for 1 of 1 sampled resident diagnosed with congestive heart failure, whose record was reviewed for Death (Resident #33); and failed to follow physician orders and to identify an incorrect dose of medication prepared by the pharmacy that nursing staff were administering to residents for 1 of 5 sampled residents observed during medication pass (Resident #235). The findings included: The facility policy, titled, Notification of Changes Policy, documented, in part, the following: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Nurses and other care staff are educated to identify changes in a resident's status and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the pharmacy failed to send the correct dose of medication (buspirone, an anti-anxiety medication) for 1 of 5 sampled residents observed during the medication pass observation (Resident #235). The findings included: A medication pass observation was made with Staff A, Licensed Practical Nurse (LPN) on 09/06/23 beginning at 10:14 AM. Staff A administered a 30 mg (milligram) tablet of buspirone to Resident #235. An observation of the label and packaging of the buspirone with Staff A on 09/06/23 at approximately 10:45 AM, revealed the documented directions to give one half (15 mg) of the 30 mg tablet. Further observation revealed whole pills were packaged in the individual bubbles of the bubble pack that was filled on 08/31/23. Photographic Evidence Obtained. Each pill was scored on one side to be broken in thirds and on the other side to be broken in half. Staff A confirmed she administered a whole tablet, and had not noticed the directions to give one half tablet. Staff A explained that usually the pharmacy would send the package…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to accurately document wound treatments, as evidenced by nurses signing off for wound care when not provided and failed to obtain written physician orders for the pressure relieving boots for 1 of 13 sampled residents, Resident #8; and failed to ensure accurate documentation related to residents' discharge, for 1 of 13 sampled residents, Resident #32. The findings included: 1a. Record review revealed Resident #8 was admitted to the facility on [DATE]. Review of the record revealed Resident #8 had a treatment order dated 08/21/23 that documented: Right heel: Cleanse with NSS [Normal Saline], pat dry and apply Hydrogel. Cover with a bordered gauze dressing, every night shift every Mon, Wed, Fri [Monday, Wednesday, Friday]. On 09/05/23 at approximately 3:30 PM, the surveyor asked Staff F, Licensed Practical Nurse (LPN), to view the wound on the right heel of Resident #8. The wound was covered with a bordered gauze dressing and dated 08/31/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.