Vida Encantada Nursing & Rehab

F-F0812

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 325065 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325065 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

LA Vida Buena Healthcare 2301 Collins Drive Las Vegas, NM 87701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41988

Residents Affected - Few Based on observation, record review, and interview, the facility failed to provide food that accommodated resident preferences for 1 (R #15) of 1 (R #15) residents observed for food preferences. This deficient practice is likely to result in weight loss due to the resident not eating or an allergic reaction to the food being served to the resident. The findings are:

A. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE REDACTED].

B. Record review of R #15's care plan, dated 05/03/24, revealed the following:

- Focus: Diet: Regular type. Regular with chopped meat.

- Interventions: Use adaptive feeding equipment - Red foam built-up utensils, lip plate, and mug with spouted lid (sippy-cup) at all meals for improved self-feeding ability. Provide diet as ordered and honor food preferences. No beans.

C. Record review of R #15's meal ticket, undated, revealed No beans.

D. On 06/10/24 at 2:17 pm during an interview with R #15, she stated she had limited choices on meals to eat, and the kitchen constantly sent her food she did not like.

E. On 06/12/24 at 12:33 pm during a lunch observation, staff served R #15 pasta with red sauce, beans, and enchiladas. R #15 stated, I don't want those [beans].

F. On 06/12/24 at 12:34 pm during an interview with Certified Nursing Assistant (CNA) #5, she confirmed R #15 was served beans and should not have been.

G. On 06/12/24 at 12:37 pm during an interview with Dietary Aide (DA) #1, she stated R #15's meal ticket says the staff should not serve the resident beans, but they did.

H. On 06/13/24 at 3:57 pm during an interview with the Dietary Manager (DM), she stated staff should not serve R #15 beans, because it says no beans on her meal ticket.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 325065 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325065 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

LA Vida Buena Healthcare 2301 Collins Drive Las Vegas, NM 87701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 41988 Residents Affected - Many Based on observation, record review, and interview, the facility failed to deliver meals consistently and timely for all 80 residents in the facility. This deficient practice could potentially lead to frustration and hunger. The findings are:

A. Record review of the facility meal times in the dining room revealed the following:

1. Breakfast: 8:05 am.

2. Lunch: 12:05 pm.

3. Dinner: 5:05 pm

B. On 06/10/24, a lunch observation revealed the following:

- At 12:24 pm, the main dining room was filled with residents, and lunch was not served.

- At 12:57 pm, staff began to serve lunch.

C. On 06/10/24 at 12:40 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated staff were supposed to serve lunch in the dining room at 12:05 pm, but it was late. LPN #1 also stated staff have served meals late ever since the facility did not have a Dietary Manager (DM).

D. On 06/10/24 at 2:19 pm during an interview with R #15, she stated staff often delivered the meals late in

the main dining room. R #15 stated other residents were upset when meals are late.

E. On 06/10/24 at 3:20 pm during an interview with R #386, she stated staff often serve meals later than the posted meal times.

F. On 06/11/24 at 8:24 am, a meal observation in the main dining room revealed staff began to serve breakfast.

G. On 06/11/24 at 12:21 pm, a meal observation in the dining room revealed staff began to serve lunch.

H. On 06/11/24 at 3:12 pm during an interview with the Registered Dietitian (RD), she confirmed staff served

the meals later than they should. The RD stated they were trying to work on staff serving meals on time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 325065 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325065 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

LA Vida Buena Healthcare 2301 Collins Drive Las Vegas, NM 87701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41988

Residents Affected - Many Based on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety when staff failed to:

1. Ensure all food items in the kitchen were labeled, dated, and stored properly.

2. Ensure refrigerated and frozen food was put away after a delivery and not left out for an extended period of time.

3. Ensure the kitchen walls, floors, and freezer floor were clean from dirt, grime, and unknown liquid.

These deficient practices are likely to affect all 80 residents identified on the resident census list provided by

the Administrator on 06/10/24. If the facility does not follow food safety guidelines, then they are likely to expose residents to food borne illnesses. The findings are:

Food Storage Findings:

A. On 06/10/24 at 10:39 am, an initial kitchen observation revealed the following:

1. One plastic tub of russet potatoes was not labeled or dated and stored in the dry storage.

2. One plastic tub of four white onions and approximately 30 red onions was not labeled or dated and stored

in the kitchen prep area.

3. One large cardboard box of red apples with approximately 30 to 40 apples was not labeled or dated and stored in the kitchen prep area.

B. On 06/10/24 at 10:56 am during an interview with Dietary Aide (DA) #1, she confirmed all findings and stated all food should be labeled and dated.

C. On 06/10/24 at 12:36 pm, a kitchen follow-up observation revealed the following:

1. One box of 75, 4 ounce (oz) cartons of [NAME] Ready Care Strawberry shakes was on a prep table and not on ice or in a refrigerator.

2. Two boxes of 15, 2 pound (lb) cartons of Papetti's Breakfast Blend Scrambled Egg Mix was on prep table and not on ice or in a refrigerator or freezer.

3. One box of 46.44 lb boneless pork butts was on prep table and not on ice or in a refrigerator or freezer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 325065 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325065 B. Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

LA Vida Buena Healthcare 2301 Collins Drive Las Vegas, NM 87701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 4. One 13.5 lb box Wheat Garlic Breadsticks made with whole grain was on the prep table and not on ice or

in the freezer. Level of Harm - Minimal harm or potential for actual harm D. On 06/10/24 at 1:11 pm during an interview with DA #1, she confirmed the findings. She stated the items were still not in the refrigerator or freezer after the delivery earlier in the morning, but they should have been. Residents Affected - Many DA #1 also stated they began to serve lunch and did not have enough staff to put the food away first.

E. On 06/13/24 at 3:26 pm, a kitchen follow-up observation revealed one 10 lb box of Double Red Provisions 100 percent (%) pure ground beef patties was open to air and stored in the freezer.

F. On 06/13/24 at 3:28 pm during an interview with the Dietary Manager (DM), she confirmed the findings.

She stated all food should be stored appropriately and put away immediately after a food delivery and the beef patties should be covered and not left open to air.

Kitchen Cleanliness Findings:

G. On 06/10/24 at 10:53 am during an initial kitchen observation, the overall facility kitchen was dirty with dirt/grease/grime on the floors, walls and baseboards.

H. On 06/10/24 at 10:56 am during an interview with DA #1, she confirmed the findings and stated they were shorthanded with staff and not cleaning like they should.

I. On 06/13/24 at 3:28 pm during a kitchen follow-up observation, the freezer floor was sticky and had brown liquid present upon entrance.

J. On 06/13/24 at 3:30 pm during an interview with the DM, she confirmed the freezer floor finding and stated

the floor should be clean and free from unknown liquid. The DM also confirmed the kitchen was still dirty and should be cleaned.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 325065