La Frontera Nursing & Rehabilitation

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the pass out of resident food was done in accordance with professional standards for food service safety for 1 of 10 residents and the storage of food in accordance with professional standards for food service safety1 of 1 unit refrigerators (resident refrigerator RR #1), 1 of 1 resident freezer (resident freezer RF #1) and 1 of 1 resident walk in pantry( walk in pantry WP#1) reviewed for storage, preparation and sanitation. The facility failed to ensure items in the refrigerators were covered and sealed to prevent exposure to air and cause cross contamination. The facility failed to ensure food items in the resident's freezer were covered or sealed to prevent exposure to air and cause cross contamination. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and 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 3 (Resident #3, Resident #17, Resident #92) of 6 residents reviewed for infection control. 1. The facility failed to implement the required elements for transmission-based precautions (specialized infection control measures used in addition to Standard Precautions for patients known or suspected to be infected with highly transmissible pathogens), including signage for Resident #3. 2. The facility failed to ensure the WCN placed a barrier between Resident #92's wound and his brief when she performed wound care on 07/15/26. 3. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote resident independence and dignity while dining for one out of ten residents observed while dining. The facility failed to ensure the dignity of Resident #26 while dining by not removing the tray the food was carried on to his table by staff. This failure could place residents who their meals in the dining room, at risk for lack of supervision, assistance, and respect.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe environment for residents in 2 of 4 hallways (Verde and [NAME]) with 2 of 2 unlocked doors in [NAME] hallway and 1 out of 4 unlocked doors Verde Hallway for non-residential rooms. 1. The facility failed to ensure a safe environment for the residents of the [NAME] Hall by not securing the clean linen closet door in the was able to be locked properly after use and lead to the possible contamination of the clean linen by a resident. 2. The facility failed to ensure a safe environment for the resident of the [NAME] Hall by not securing the door of the storage room with trash, dirty linen and a sink was properly closed shut and locked after use. 3. The facility failed to ensure the shower room door in the Verde Hall waslocked which contained a hand sanitizer, mechanical lift, and a large wheel chair. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 (Resident #38) of four residents reviewed for physical environment. The facility failed to ensure Resident #38 had a working call light in the room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 4 of 4 residents (Resident #7, #24, #25, and #26) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting for Resident #7, #24, #25, and #26. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 5 residents (Resident #9) reviewed for pharmacy services. 1. The facility failed to clarify the blood pressure parameters for Resident #9's Midodrine order. 2. The facility failed to administer Resident #9's order for Midodrine as prescribed in May of 2025 by administering Midodrine 8 times outside of physician ordered parameters. These failures could place residents at risk for complications, as well as jeopardize their health and safety.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure the ice machine chute was free of scratches with removable black substances in the scratches and around them. The facility failed to ensure the meat slicer was covered properly when not in use and remained free of dust and debris. The facility failed to ensure hairnets were worn before entering the kitchen and made readily available. The facility failed to ensure the underside of the shelf directly above the steam table holding food was free of grime. The facility failed to ensure a pair of black plastic tongs were free of crevices and not melted. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident and/ or their representative and the IDT were invited to attend/participate in the care plan meetings including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #25) reviewed for care plan timing and revision. The facility failed to ensure Resident #25 had quarterly care plan reviews or meetings that included the appropriate IDT members and resident and/or resident representative in February 2025 and May 2025 (2 out of 3). The facility failed to ensure the care plan was revised within 7 days after the quarterly assessment that was dated 2/19/25. These failures could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect. The facility failed to report to the local law enforcement agency within the allotted time frame of 24 hours on 01/14/2025 around 6:30 PM when housekeeper A notified the administrator and DON of her suspicion of abuse regarding Resident #1. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of one residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 2 hours. On 04/21/2024, Resident #1 eloped from the facility through the employee dining area (formally assisted living dining area) door sometime after 1:00pm. The facility was notified by another local facility located approximately one block away at approximately 2:30 pm, that Resident #1 was brought into their facility after a passerby saw Resident #1 on the sidewalk by the road next to their facility. The passerby assumed Resident #1 resided at their facility since Resident #1 was located across the street. [...]

Inspectors wroteBased on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility did not have a completed Facility Assessment specific to cyber-attacks. This failure could place all residents at a risk for a lack of necessary resources and services. Findings Included: During an observation on 08/31/2024 at 11:00AM the facility had multiple resident's MARs and TARs on the conference table, and additionally upon further observation the clinical staff were using paper charting without any use of internet capable devices including computers and/or laptops. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible and systematically organized for 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) who were reviewed for medical records. The facility failed to maintain accurate, thorough, complete and readily accessible medical records including physician orders, daily documented progress notes, blood pressure readings for residents that take blood pressure medications, glucose reading results for residents that have orders for glucose checks, MARs, and TARs for residents within the facility from 08/28/2024 thru 08/30/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community, for 5 of 7 residents (Residents #17, #19, #26, #33, and #56) reviewed for individual in-room activity programming, as evidenced by: 1. Resident #17 did not have an in-room activity plan developed and implemented to meet her individual interests, abilities, and needs. 2. Resident #19 did not have an in-room activity plan developed and implemented to meet her individual interests, abilities, and needs. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and 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 one of three residents (Resident # 81) reviewed for infection control practices. CNA A failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #81. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteFACILITY Sufficient and Competent Nurse Staffing Based on observation, interview, and record review the facility failed to ensure that the daily nurse staffing information, including the facility name, the current date, the total number and actual hours worked by RNs, LVNs, and CNAs, and the resident census, was posted on a daily basis for 3 of 3 staffing postings reviewed for daily staffing. The facility failed to update the daily staffing information posting on (include the dates) to reflect the actual hours worked by licensed and unlicensed staff. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.