La Dora Nursing And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in thefacility's only kitchen. The facility failed to ensure food items were labeled, dated, and sealed properly in stand-by refrigerator 1 of 2.The facility failed to ensure food items were labeled, dated, and sealed properly in all 2 stand-by freezers. These failures could have affected residents by placing them at risk for cross-contamination and foodborne intoxication.Findings included: Observation on 04/22/26 at 9:14 AM reflected smoked sausage in a metal bowl covered with foil, removed from its original package, with no label and no use-by date in refrigerator 1. Observation on 04/22/26 at 9:15 AM of stand-by freezer 2 reflected the following: 3 clear bags of smoked sausage in original packaging with no label or use-by date.1 bag of fish nuggets in a blue plastic bag, in original packaging, that had been opened and partially twisted closed, with no label, no use-by date, and not sealed properly.1 bag of…

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 ensure all drugs and biologicals were stored in locked compartments for two of three medication carts (Nurse med carts #1 and #2) in that: LVN B left Nurse Med Cart #1 unlocked and unattended on 02/11/25 and on 02/12/25. LVN C left six medications on top of Nurse Med Cart #2 while the cart was unattended and out of the nurse's view on 02/12/25. These failures could place residents at risk of their medications being stolen or misused and health complications related to accidental ingestion of drugs and/or biologicals, including hospitalization. Findings included: During an observation and interview on the secure unit on 02/11/25 at 10:20 AM, it was revealed that LVN B left Nurse Med Cart #1 unlocked and unattended in the hallway against the wall by room A1 with the drawers facing out into the hallway. Nurse Med Cart #1 was unlocked with the drawers able to be opened and accessed. Multiple residents were seated in the dining room with the…

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 facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. The failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observations of the facility's kitchen refrigerator on 02/11/2025 at 9:00 AM revealed the following items were not sealed, labeled, or dated with any dates: 1 plastic bag with 7 hardboiled eggs not labeled or dated. 1 large container of hot sauce almost empty not dated. 1 open container exposed to air in refrigerator with bell peppers and onion not sealed , labeled, or dated. Observations of the facility's kitchen freezer on 02/11/2025 at 9:15 AM revealed the following items were not sealed, labeled, or dated: 1 box of frozen beef patties not dated. Interview with the Dietary Manager on 02/12/2025 at…

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 maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #44 and Resident #106) reviewed for infection control in that: 1. LVN A failed to sanitize her hands after moving Resident #44's floor mat before touching his bedside table and did she not change her gloves after touching the door, adjusting the bed and touching the privacy curtain before touching Resident #44's G-tube. 2.LVN A, CNA D, and CNA E failed to prevent cross contamination of Resident #44's care items during wound care. 3. LVN C failed to sanitize the stethoscope (this is a medical device used for listening to internal sounds in the body) that was on her neck covered with hair before placing it on Resident #106 stomach to listen to his bowel sounds and g-tube placement. These deficient practices could place…

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 interview and record review, the facility failed to ensure resident was free from abuse and neglect for 1(Resident #1) of 3 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure that Resident #1 was free from neglect when ST-A entered the code to the door to let Resident #1 out of the facility. Resident #1 was seen by another staff and brought back into the facility. This failure could place residents at risk of neglect, injury, and psychosocial harm. Findings included: Record review of Resident #1's face sheet, dated, 01/07/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included age related cognitive decline ( a gradual decline in some thinking abilities), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 14 residents (Residents # 20, #38, #11, #42, #29, and #18) reviewed for infection control. The facility failed to ensure residents with a COVID-19 positive status in the secured unit (Residents #42, #29, and #18) were not cohorted with residents with a COVID-19 negative status (Residents #20, #38, and #11) and that CNA A failed to inform the facility when she did not feel well on 12/21/23 and continued to work on the secured unit prior testing positive for COVID-19. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness. Findings included: Interview on 01/02/24 at approximately 9:15 AM, the DON stated three residents (Resident #42, #29, and #18) were on…

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 interview and record review, the facility failed to develop a baseline care plan within 48 hours for 1 of 4 residents (Resident #204) reviewed for baseline care plans. The facility failed to ensure Resident #204's baseline care plan was completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs. Findings included: Record review of Resident #204's admission record, dated 01/05/2024, revealed an [AGE] year-old male who admitted to the facility on [DATE] with no diagnoses completed. Length of stay 6 days at time of record review on 01/05/24. Record review of Resident #204's MDS assessment, dated 01/04/2024, reflected a BIMS score of 9, indicating moderately impaired cognition. Section K -Swallowing/Nutritional status of the MDS reflected Resident#204 had a mechanically altered diet; required change in texture of food or liquid (e.g , pureed food, thickened liquids) and he was on a therapeutic diet (e.g , low salt, diabetic,…

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 13 residents (Resident #28, Resident #30, and Resident #65) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #30 ' s tube feeding status was documented in the care plan. 2. The facility failed to ensure Resident #65 ' s wandering and elopement risk was documented in the care plan. 3. The facility failed to ensure Resident #28 ' s PICC (Peripherally Inserted Central Catheter) was documented in care plan. These failures could place residents at risk of not receiving adequate care and not having…

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 ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #28) of 4 residents reviewed for intravenous fluids The facility failed to ensure Resident #28 received PICC (Peripherally Inserted Central Catheter -PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes as ordered every 2 days. This failure places residents at risk of bacterial contamination and risk of infection. Findings included: Record review of Resident #28 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included unspecified organism sepsis (infection in the blood or whole body), type 2 diabetes, unspecified Alzheimer ' s diseases, high blood pressure, other viral pneumonia, muscle wasting and dying multiple sites, unsteady on…

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 maintain a medication administration error rate below 5% for 2 of 24 (error rate 8.33%) opportunities for errors during medication pass. Facility failed to ensure Intravenous (IV) Medication was administered as ordered for Resident#28. Facility failed to ensure correct medication dose was administered to Resident #48. These failures could place residents at risk for significant medication errors and jeopardize the residents ' health and safety. Findings included: Review of Resident #28 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included unspecified organism sepsis (infection in the blood or whole body), type 2 diabetes, unspecified Alzheimer ' s diseases, high blood pressure, other viral pneumonia, muscle wasting and dying multiple sites, unsteady on her feet and lack of coordination. Record review of Resident #28 ' s Physician order summary dated…

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.