San Luis Care Center

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations. Specifically, the facility: -Failed to update the facility assessment annually; -Failed to include all current diagnoses the facility currently cared for; and, -Failed to develop a facility assessment which included staff education and staff competencies. Findings include: I. Facility assessment The facility assessment was provided by the nursing home administrator (NHA) on 6/17/24 at 11:25 a.m. It was updated on 2/27/23 and reviewed by the quality assurance performance improvement (QAPI) committee on 2/28/23. The facility assessment failed to include the following: -Diagnoses of current residents including intermittent explosive disorder (mental disorder that causes sudden, impulsive and aggressive outbursts) , schizophrenia (mental illness causing episodes of psychosis), anxiety, seizures and methicillin resistant Staphylococcus aureus (MRSA); -Include staff…

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 in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three of five CNAs reviewed. Specifically, the facility: -Failed to ensure CNA #3 and CNA #5 received annual dementia management training; -Failed to ensure CNA #1 received annual abuse training; and, -Failed to ensure CNA #5 received 12 hours of annual training. Findings include: I. Record review of insufficient in-service training in the last 12 months for three CNAs CNA #1 was hired on 9/7/22. She had not had annual abuse training in the past 12 months. CNA #3 was hired on 5/3/23. She had not had annual dementia management training in the past 12 months. CNA #5 was hired on 1/13/22. She had not had annual dementia management training or 12 hours of training in the past 12 months. II. Interview The director of nursing (DON) and staff development director (SDC) were interviewed together on 6/18/24 at 5:20 p.m. The SDC said she could not find documentation that the facility had…

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 inform one (#39) of three residents reviewed for beneficiary notices and appeal rights out of 21 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to: -Obtain a signature from the resident's authorized representative on liability notices for Resident #39, who had memory impairments; and, -Provide written notification of Medicare Non-Coverage letters to the resident's representative of Medicare-covered services ended for Resident #39. Findings include: I. Facility policy The Denial or End of Benefits policy, revised 7/11/23, was provided by the nursing home administrator (NHA) on 6/19/24 at 10:40 a.m. It revealed in pertinent part, The Denial or End of Benefits process is in place to help the resident and family understand their options and needs they might have regarding their care. Upon end of coverage under Medicare, the resident and family will receive notice that specifically states the reason for non-coverage. The NOMNC (Notice of Medicare Non…

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 record review and interviews, the facility failed to develop a comprehensive care plan for one (#18) of three residents out of 21 sample residents for services to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being that included measurable objectives and timeframes. Specifically, the facility failed to develop an activities care plan focus for Resident #18. Findings include: I. Facility policy and procedure The Activities Progress Notes policy, revised 9/21/23, was provided by the nursing home administrator (NHA) on 6/19/24 at 12:11 p.m. It read in pertinent part, Progress notes are written at least every 90 days from the date of the last progress note. These notes will include the status of activity problems, needs and concerns identified in the care plan, a description of the resident's progress towards achieving care plan goals, the documentation of specific recreation approaches in the care plan and the evaluation of approaches toward achieve goals…

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, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals for two (#3 and #25) of three residents out of 21 sample residents. Specifically, the facility failed to: -Offer non-pharmacological interventions for pain management for Resident #3 and Resident #25; and, -Ensure the location of pain was identified when administering pain medications for Resident #3 and Resident #25. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, revised 9/12/23, was provided by the nursing home administrator (NHA) on 6/19/24 at 11:24 a.m. It revealed in pertinent part, The facility will address and treat the underlying causes of pain, to the extent possible and develop and implement both non-pharmacological and pharmacological interventions and approaches to pain management. Identify and use…

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 record review and interviews, the facility failed to ensure residents who (#25) required dialysis received dialysis services consistent with professional standards of practice for one (#25) of one resident reviewed for dialysis out of 21 sample residents. Specifically, the facility failed to: -Ensure the physician's order for Resident #25' s fistula care was followed; and, -Ensure the physician was notified when Resident #25' s fistula site healed. Findings include: I. Facility policy and procedure The Hemodialysis Offsite policy, revised 8/23/23, was provided by the nursing home administrator (NHA) on 6/17/24 at 11:21 a.m. It read in pertinent part, The facility should provide immediate monitoring and documentation of the status of the resident' s access site upon return from the dialysis treatment to observe for bleeding or other complications. Notify the physician of any change in mental or physical status. II. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According…

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 act promptly and resolve the concerns of resident groups' grievances and recommendations concerning issues of resident care and life in the facility of 29 sample residents. Specifically, the facility failed to ensure resident group concerns and grievances related to call light response times were resolved in a timely manner. I. Policy and procedure Review of the Grievance Procedures and Concern and Comment Program policy, dated 5/6/19, provided by the health information management (HIM) staff on 2/26/2020 at 11:23 a.m. revealed in part, Use of the Concern and Comment Program in response to a reported concern: Fosters a timely and quality response to the concern and/or comment; Allows for identification of possible trends and patterns; Identifies special needs of families and/or residents; ensures appropriate follow-up and systemic analysis. II. Resident group interview A group interview was completed on 2/24/2020 at 10:41 a.m. with 10 residents the facility deemed as interviewable. The group said the call light response…

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 interviews and record review; the facility failed to honor one (#11) of one resident's rights to participate in a person centered care plan out of 29 sample residents. Specifically, the facility failed to: -Allow Resident #11 and her family to participate in the development and implementation of the person centered care plan with a care conference after each quarterly assessment. Findings include: I. Facility policy and procedure The Resident Assessment Instrument and Care Plan policy was provided by the health information manager on 2/26/2020. It read, in pertinent part, The resident assessment instrument (RAI) is not all inclusive therefore other sources of information are to be included when developing an individualized person-centered care plan for each patient that is reviewed by the interdisciplinary team with each assessment including the patient and other participants as the patient desires. II. Resident status Resident #11, age above 90, was admitted on [DATE]. According to the February 2020…

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 and interviews the facility failed to carry out activities of daily living (ADL) for one (#4) of four residents reviewed for the necessary services to maintain good grooming and personal hygiene out of 23 sample residents. Specifically, the facility failed to assist and provide Resident #4 with her scheduled showers according to her plan of care. Findings include: A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the February 2019 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, malnutrition, delirium and depression. The 11/6/18 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required extensive assistance and one person physical assist for transfers, toilet use, personal hygiene and bathing. The resident did not reject care. B. Observations On 2/4/19 at 11:44 a.m. the resident…

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 resident observations, record review, and interviews, the facility failed to provide adequate supervision for one (#26) of four residents reviewed for accidents out of 23 sample residents. Specifically, the facility failed to ensure distant supervision was provided during meals according to the speech therapy recommendation for Resident #26. I. Facility policy and procedure The Aspiration Precautions policy and procedure, undated, provided by the nursing home administrator (NHA) on 2/7/19 at 1:00 p.m., read, in pertinent part, resident placed on aspiration precautions are supervised during all intake by mouth. II. Resident #26 A. Resident #26 status Resident #26, age [AGE], was admitted [DATE]. According to the February 2019 computerized physician orders (CPO), diagnoses included oropharyngeal dysphagia and gastro-esophageal reflux disease (GERD. The 1/7/19 minimum data set (MDS) assessment revealed she had no memory impairments but did require some assistance with decision making. She required…

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, record review and interviews, the facility failed to provide timely dental services for one (#4) out of one of one reviewed for dental services out of 23 sample residents. Specifically, the facility failed to: - Ensure Resident #4s dentures were replaced timely after they were lost in the facility. Findings include: A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the February 2019 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, malnutrition, delirium and depression. The 11/6/18 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required extensive assistance and one person physical assistance for personal hygiene which included oral care. The Oral/dental section was not completed. The 8/13/18 minimum data set (MDS) assessment revealed The Oral/dental section identified the resident had…

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, and staff interview, the facility failed to provide therapeutic diets consistent with physician orders for one (#42) of one residents reviewed for therapeutic diets out of 23 sample residents. Specifically, the facility failed to ensure: -Resident #42 received fluids as ordered by the physician, -Document refusals by the resident, and education given to the resident; and -Encourage the resident to follow the fluid orders. Findings include: A. Resident status Resident #42, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 computerized physician orders (CPO), diagnoses included diabetes mellitus type II. The 1/16/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented the resident required limited assistance with one person during meals. The MDS did not document the resident required a special diet. B. Record…

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.