Inspection Reports for
La Posada

There is an open complaint investigation (#28-AS-20260211084916) related to ceiling damage in rooms 112 and 204 and missing service plans in resident files.

The facility was found to have several deficiencies including unlocked hazardous items in the Memory Care Unit, missing mattress pads in multiple resident rooms, incomplete staff training and personnel records, lack of proof of recent emergency drills, and residents not receiving prescribed modified diets. Several resident medical assessments were also outdated.

Deficiencies were observed including missing staff files, incomplete resident service plans, and four residents missing physician ordered medications. A Type A citation was issued for the medication deficiency.

The complaint alleged inadequate food service, staff retaliation against a resident's authorized representative, failure to obtain admission agreement signatures, unequal treatment of a resident, and failure to follow visitor directives. Only the inadequate food service allegation was substantiated; the others were unsubstantiated due to insufficient evidence.

The investigation substantiated that the facility failed to provide adequate snacks between meals in the Memory Care Unit, violating food service requirements. Other allegations related to staff retaliation, admission agreement signatures, equal treatment of residents, and visitor directives were found unsubstantiated.

The complaint was substantiated based on evidence that staff failed to notify the authorized representative of a bruise observed on 2025-01-17, did not consistently reposition the resident every 2 hours despite a pressure injury, and the resident sustained an unexplained bruise. Staff interviews, record reviews, and observations supported these findings.

The investigation substantiated the allegations that staff failed to notify the resident's authorized representative about a bruise, did not consistently reposition the resident every 2 hours as required, and the resident sustained an unexplained bruise. Deficiencies were cited related to personal rights, reporting requirements, and personnel training.

The complaint alleged that on April 3, 2025, facility staff prohibited a former staff member from visiting resident R1 who was transitioning. The allegation was substantiated based on interviews and record review.

The investigation substantiated that former staff were prohibited from visiting a resident nearing end of life, which was not explicitly stated in facility policies. This posed a potential health, safety, and personal rights risk to the resident.

The complaint was unsubstantiated. Allegations included rough handling of a resident causing injury and failure to prevent a resident from falling out of a window. The investigation included interviews with staff and residents, review of records, and physical inspection. The citation related to rough handling was dismissed.

The investigation found that while the incident and resulting injuries occurred, there was insufficient evidence to prove the resident required additional supervision. One citation was dismissed, and another deficiency related to personnel requirements was identified with a plan of correction required.

The complaint investigation was substantiated based on evidence gathered from staff and resident interviews, record reviews, and facility inspections. Allegations included rough handling of residents causing injury, failure to prevent falls, medication errors including alteration and non-administration, and improper storage of resident files. Other allegations about facility maintenance and cleanliness were unsubstantiated.

The investigation substantiated allegations that staff handled a resident roughly causing injury, failed to prevent a resident from falling out of a window, altered residents' medications, did not administer medications properly, and did not store resident files correctly. Other allegations regarding water damage, room cleanliness, and pest control were found unsubstantiated.

The complaint investigation was substantiated for allegations including improper transfer causing injury, delayed medical attention, inadequate toileting care, medication mismanagement, and unsafe environment due to unlocked doors. Allegations of failure to report incidents timely and inadequate food service were unsubstantiated due to insufficient evidence.

The investigation substantiated several allegations including improper resident transfer causing injury, failure to seek timely medical attention, inadequate toileting care, medication mismanagement, and unsafe environment due to unlocked doors. Two allegations regarding incident reporting and food service were unsubstantiated.

The visit was triggered by a complaint investigation under control number 28-AS-20240805162120. The deficiency cited relates to failure to timely report a serious injury to the licensing agency.

A deficiency was cited for failure to submit an incident report within seven days after a resident sustained a serious injury during transfer. The incident report was faxed late, posing a potential health and safety risk.

The inspection found deficiencies related to water temperature exceeding regulatory limits, medication administration errors, and staff training and health screening deficiencies. The facility has plans of correction due for these issues.

The complaint alleged that the resident's responsible party never received a copy of the signed Admission Agreement after multiple requests. The allegation was substantiated based on record review and interviews. A civil penalty is being assessed.

The investigation found that the facility failed to provide the correct admission agreement to the resident's authorized representative until multiple requests were made, with the copy provided being from a former licensee. The allegation was substantiated and a civil penalty is being assessed.

The complaint was substantiated. Allegations included failure to meet residents' health needs and failure to ensure annual medical assessments. Investigation included interviews and record reviews confirming these issues for resident R1.

The investigation substantiated that the facility failed to follow up on specialist referrals for a resident and did not ensure annual medical assessments were conducted. Staff observed deterioration in a resident's health but did not notify the physician or request medical exams, posing a potential health and safety risk.

The complaint investigation was substantiated for medication administration issues with evidence of multiple residents not receiving medications as prescribed. The allegation of lack of supervision leading to resident assaults was unsubstantiated due to insufficient evidence.

The medication administration allegation was substantiated with evidence that med-tech staff did not dispense medications to at least 10 residents as directed by physicians, with some residents going 2-5 days without medications. The allegation of lack of supervision resulting in resident assaults was unsubstantiated due to insufficient evidence.

The visit was triggered by a complaint investigation with control number 28-AS-20240829114254.

The facility was found deficient for not posting 'No Smoking-Oxygen in Use' signs outside resident room doors where oxygen tanks were present, posing a potential health and safety risk.

The complaint alleged that staff did not ensure the care needs of resident (R1) were met due to missed dialysis appointments caused by transportation issues. The allegation was substantiated based on interviews, record reviews, and confirmation from medical providers.

The investigation substantiated that resident (R1) missed multiple dialysis appointments on June 6, 2024, June 18, 2024, June 20, 2024, June 22, 2024, and July 4, 2024, due to transportation failures by Access transportation services and lack of alternate arrangements by the facility. The facility does not provide transportation services as it lacks an assigned driver, which violates the admission agreement requiring transportation to medical appointments.

The complaint investigation found the facility did not submit a required Unusual Incident/Injury Report concerning a resident's fall on 10/14/2022.

The facility failed to meet reporting requirements by not submitting an Unusual Incident/Injury Report concerning a resident's fall on 10/14/2022, which posed a potential health, safety, or personal rights risk to residents in care.

The complaint investigation was substantiated. Resident #1 sustained a left hip fracture from a fall due to neglect and lack of supervision. Staff did not seek timely medical attention, delaying treatment for several days. An immediate civil penalty of $500 was issued for neglect/lack of supervision contributing to the delay in medical care.

The investigation substantiated that Resident #1 sustained a left hip fracture due to a fall under facility care and that the facility neglected to provide timely medical attention, resulting in delayed treatment. The facility was found to have insufficient supervision and care, contributing to the resident's injury and delayed medical response.

The complaint investigation was substantiated. Allegations included failure to refill medication timely, medication errors, and falsification of documents. The investigation found sufficient evidence to corroborate all allegations.

The investigation substantiated that staff failed to order insulin medication timely, resulting in a dangerous blood sugar level for a resident. Staff also gave a resident another resident's medications, and falsified incident reports related to these events. The facility failed to follow proper medication administration and incident reporting protocols.

The complaint alleged that staff were not following residents' care plans and were not providing proper meal service. The investigation found these allegations substantiated based on interviews and record reviews.

The investigation substantiated that staffing shortages led to residents not receiving showers as scheduled and delays in feeding assistance. Residents and staff interviews, along with document reviews, confirmed these deficiencies posed potential health and safety risks.

The complaint alleged the facility was understaffed, with staff working 12-hour shifts and failing to meet bathing, incontinence care, and feeding needs timely. Interviews with residents and staff confirmed the allegation. The facility had staffing shortages from August 2021 through February 2022, including reliance on registry staff who were sometimes absent or quit quickly. The allegation was substantiated.

The investigation substantiated the allegation of staffing shortages between August 2021 and February 2022, including use of registry staff and 12-hour shifts, which resulted in insufficient care to residents and posed a potential health and safety risk.

The inspection found several deficiencies including use of outdated admission agreements, missing mattress pads on beds, staff without current 1st Aid/CPR certificates, a staff member not properly associated with the facility, discarded furniture and safety hazards in the environment, lack of recent emergency drills, and exceeding the approved hospice waiver capacity.

Two citations were issued: one for unfilled PRN medications for two residents and another for an unlocked drawer containing scissors and sharp office supplies in the Memory Care Unit. An annual continuation visit will be conducted due to time constraints.

The complaint alleged that facility staff stole a resident's money. The allegation was substantiated based on interviews and record reviews. The Activities Director took money from a resident but did not provide the lottery tickets purchased. The staff member was terminated for unrelated reasons. A police report was not filed due to the loss value being under $100.

The investigation substantiated that the Activities Director (staff S1) took $10 from a resident (R1) to buy lottery tickets but did not provide the tickets. Staff S1 was terminated for unrelated attendance issues. The facility documented the theft but did not file a police report due to the low value of loss.

The visit was triggered by complaint investigation control # 28-AS-20230630083050 regarding outdated medical assessments for Dementia residents.

The facility failed to update annual medical assessments for two Dementia residents, with one resident's physician report last updated in 2020 and the other's in 2021, violating Title 22 requirements.

The allegation was that a resident in the Memory Care Unit physically assaulted another resident. Interviews and record reviews indicated that although the incident may have occurred, there was insufficient evidence to prove the allegation. The allegation was unsubstantiated.

The investigation found insufficient evidence to substantiate the allegation of a resident being struck due to adequate staffing and cognitive impairments of involved residents. No health or safety concerns were observed during the facility tour.

The complaint alleged the facility failed to provide resident records after a formal records request was made on January 26, 2023. The facility provided the records late on February 2, 2023. The allegation was substantiated.

The investigation found that the facility did not provide requested resident records within the required two business days, instead providing them five business days later. The allegation was substantiated based on record review and interviews.

The facility was found to have several deficiencies including expired food handling certification for the Dining Services Director, missing mattress pads in multiple rooms, non-functional auditory alarms in the Memory Care unit, missing window screens in the 2nd floor game room, and residents missing medications ordered by their physicians.

The facility was found to be generally compliant with operational and safety standards, including fire clearance and physical plant conditions. Several items require correction, including submission of a surety bond, a first aid manual, updated plan of operation, and corrected facility sketch room names.