Centro De Cuidado Prolongado San Lucas

Inspectors wroteBased on observation and interview the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. This affected all residents.

Inspectors wroteBased on interview with Clinical Manager (employee # 1) and document review performed on 3/27/2026 at 10:00 AM, it was determined that the facility failed to ensure proper transmission of Payroll Based Journal-PBJ data. 1. During an interview performed on 3/27/2026, 10:00 AM with Clinical Manager (employee # 1), she stated that she submitted all quarterly reports as requested and that the system return a confirmation report with status submission as completed. She provided a document named Submission List (see attachment), which indicates that on 10/17/2025 at 11:08 AM a report was received, identified by the clinical manager as the fourth quarterly report of 2025 and on 02/09/2026 at 9:16 AM as the first quarterly report of 2026.2. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain all mechanical in safe and operational condition.

Inspectors wroteBased on observations of the physical environment and facility staff interviews performed on 03/25/2026 through 03/27/2026 from 8:00 AM through 5:00 PM, it was determined that the facility failed to promote the resident right to receive service in a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. This deficient practice was observed on 3 out of 8 rooms at the facility visited.

Inspectors wroteBased on medical records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that the baseline care plan for each resident includes the instructions, services and treatments needed to provide effective person-centered care for 2 out of 14 records reviewed (R.R #10 and #34).

Inspectors wroteBased on records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that facility personnel develop and implement a comprehensive person-centered care plan for each resident according with resident needs for 6 out of 14 records review (R.R #1, #3, #10, #11, #33 and #34).

Inspectors wroteBased on medical records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that facility personnel developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment according with resident needs for 5 out of 14 records review (R.R #1, #3, #11, #33 and #34).

Inspectors wroteBased on the review of the Skilled Nursing Facility (SNF) Beneficiary Notification of four (4) resident discharge, it was determined that the facility failed to ensure to inform each Medicare-eligible resident, in writing, at 48 hours previous to be discharge the Notice Medicare Non- Coverage in 1 out of 4 supplemental sample Resident (R) #38.

Inspectors wroteBased on records reviewed (R.R), resident and staff interviews, it was determined that the facility failed to ensure that sign and date the medical orders in the medical record, related to the urinary catheter insertion for 1 out of 14 records reviewed (R.R #11).

Inspectors wroteBased on records reviewed (R.R) and staff interviews, it was determined that the facility failed to ensure that a monthly drug regimen review was complete by a consultant pharmacist for 1 out of 14 records review (R.R # 2).

Inspectors wroteBased on interview with director of nursing (employee # 8) and record review performed on 3/27/2026 at 11:20 AM, it was determined that the facility failed to ensure reasonable efforts to review or adjust the individual resident's food plan to meet the specific needs of assistance during meals.

Inspectors wroteBased on interview with director of nursing (employee # 8) and document review performed on 3/27/2026 at 10:20 AM, it was determined that the facility failed to ensure the designation of a charge nurse in each shift to perform the specific responsibilities designated by the facility.

Inspectors wroteBased on review of Quality Assessment Performance Improvement- QAPI and interview with facility director of institutional program (employee #2) on 03/27/2026, it was determined that the facility failed to maintain a QAPI committee with the participation of the Medical Director or his/her designee; and Infection Control Officer in each QAPI committee meeting.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right and exercise of right which can affect all admitted residents. This Constituted and Immediate Jeopardy to the health and safety for residents.

Inspectors wroteBased on review of policies and procedures with the Nursing Supervisor (employee #15), Acting Manager (employee # 18) was interviewed on 09/09/2024 at 9:00 AM through 9:45 AM, it was determined that the facility failed to secure itself by failing to appoint the services of a full-time Director of Nursing. The deficient practice can affect all residents admitted at the facility. This Constituted and Immediate Jeopardy to the health and safety for residents.

Inspectors wroteBased on interview with the facility human resources personnel (employee #11), it was determined that facility failed to demonstrate is being managed in a manner that enables it to use resources effectively and efficiently. This Constituted and Immediate Jeopardy to the health and safety for residents.

Inspectors wroteBased on review of governing body rules and regulations and committee meetings, it was determined that facility failed to demonstrate that had a governing body, or designated persons functioning as a governing body, legally responsible for establishing and implementing policies regarding the management and operation of the facility. This Constituted and Immediate Jeopardy to the health and safety for residents.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right to designate a representative in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident has the right to be informed of, and participate in his or her treatment.

Inspectors wroteBased on review of policies and procedures and interview with nursing supervisor (employee #15), it was determined that facility failed to promote the right of each resident to sign the forms stating they understand their condition and the proposed treatment, and that they agree to the treatment. This deficient practice was identified in 2 out of 2 closed records (CR) of residents that receive services at the facility. (CR #3 and CR #4).

Inspectors wroteBased on the review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the residents' right to self-administer medications if the interdisciplinary team determined that this practice is clinically appropriate.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to choose his/her attending physician.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be treated with respect and dignity.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to receive services with reasonable accommodation of resident needs and preferences.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to share a room with his or her spouse, with his or her roommate of choice when practicable when residents live in the same facility and receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right refuse to transfer to another room in the facility.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right promote and facilitate resident self-determination through support of resident choice.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right provide immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to receive visitors of his or her choosing at the time of his or her choosing

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right inform v and equal visitation privileges.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to organize and participate in resident groups in the facility.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to choose or refuse to perform services for the facility.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to manage his or her financial affairs.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to Accounting and Records of personal funds

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to notice of certain balances.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to Assurance of financial security.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicare.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay.

Inspectors wroteBased on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to access personal and medical records pertaining to him or herself.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to receive notices orally and in writing in a format and a language he or she understands.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to post, in a form and manner accessible and understandable to residents, at list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to notification of changes.

Inspectors wroteBased on records reviewed (RR), it was found that the facility failed to ensure that resident understand the right to be oriented of the Important Message (IM) at the admission for 2 out of 2 resident discharged home. (RR#3 and RR#4).

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to personal privacy and confidentiality of his or her personal and medical records.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to safe environment.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to grievances.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to contact with external entities.

Inspectors wroteBased on the review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, and Exploitation.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, misappropriation of resident property, and exploitation.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from Abuse, Neglect, and Exploitation or involuntary seclusion.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.

Inspectors wroteBased on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to be free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident right to not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, include training to the skill personnel.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported.

Inspectors wroteBased on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to ensure that all alleged violations are thoroughly investigated, and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident

Inspectors wroteBased on interview with the facility appointed Minimum Data Set (MDS) Coordinator (employee #5), it was determined that facility failed to demonstrate that is capable of transmit to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

Inspectors wroteBased on two records reviewed R.R.' it was found that the facility failed to ensure that to newly admitted resident was developed and implement a baseline care plan within 48 hours of a resident's admission with the minimum healthcare information necessary to properly care for a resident for 1 out of 2 RR .(RR#101)

Inspectors wroteBased on interview with Nursing Supervisor (employee #15) on 09/09/2024 at 9:45 AM, It was determined that the facility failed to ensure it had a policy and procedure that the residents received appropriate treatment and assistive devices to maintain their visual and hearing abilities.

Inspectors wroteBased on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:00 AM, it was determined that the facility failed to ensure have a policy and procedure so that residents receive care consistent with the standard of professional practice, necessary care and treatment including medical and nursing care and services when they need a urostomy.

Inspectors wroteBased on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:20 AM, it was determined that the facility failed to ensure that residents who have a prosthetic device receive care and assistance in the resident's goals and preferences in accordance with the comprehensive plan of care for wearing and using the prosthesis.

Inspectors wroteBased on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:30 AM, it was determined that the facility failed to ensure that trauma-survivor residents receive competent, trauma-informed care in accordance with professional standards and mitigate triggers that may re-traumatize the resident.

Inspectors wroteBased on review of policies and procedures with the Nursing Supervisor (employee #15) on 09/09/2024 at 10:42 AM, it was determined that the facility failed to ensure the risks and benefits of bedrails for residents. The facility must ensure the proper installation, use and maintenance of bedrails.

Inspectors wroteBased on review of policies and procedures, records reviewed, and interview, with Administrator (employee #10), it was determined that the facility failed to have an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders.

Inspectors wroteBased on review of policies and procedures, record review, and interview, with Administrator (employee #10), it was determined that the facility failed to have staff who provide direct services to residents with the appropriate competencies and skills through an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders.

Inspectors wroteBased on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any laboratory services (by contract) in order to provide those services at the facility.

Inspectors wroteBased on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any blood bank services (by contract) in order to provide those services at the facility.

Inspectors wroteBased on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any radiology and other diagnostic services (by contract) in order to provide those services at the facility.

Inspectors wroteBased on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any dental services in obtaining routine and 24-hour emergency dental care (by contract) in order to provide those services at the facility.

Inspectors wroteBased on observations of the physical environment, with Engineering Director(employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficiency can affect all residents.

Inspectors wroteBased on observations and interview with administrative dietitian (employee #3), it was determined that the facility failed to have in place a policy regarding use and storage food brought to residents by family and other visitors.

Inspectors wroteBased on interview with the Physical Therapy Supervisor (employee #16) on 09/10/2024 at 11:00 AM through 12:00 PM, it was determined that the facility failed to secure that speech-language pathology services were not available are required in the resident's comprehensive plan of care.

Inspectors wroteBased on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to determine if they are going to have a relationship with any hospice facility (by contract) in order to provide those services at the facility.

Inspectors wroteBased on interview with administrator (employee #10) and review of Payroll Based Journal reporting system policies, procedures it was determined that facility failed to establish the structure to comply with the mandated electronically submission of data required by Center for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on reviewed of the quality assessment performance improvement (QAPI) program conducted on 09/10/2024 from 8:00 AM to 4:00 PM and interview with Quality and Service Coordinator to Client (employee #17), it was determined that the facility did not demonstrate Nursing Director participation in its quality assurance committee.

Inspectors wroteBased on review of policies and procedures and interview with infection control officer (employee # 1), it was determined that facility failed to develop and implement policies, procedures and structure to comply with COVID-19 immunizations and other requirements related with COVID-19 immunizations.

Inspectors wroteBased on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics program, with respect to a facility.

Inspectors wroteBased on observations of the physical environment, with Infection control officer (employee #1) performed on 09/09/2024 from 9:50 AM through 11:00 AM, it was determined that the facility failed to ensure resident care equipment is in safe operating condition. This deficient practice had the potential to affect 2 out of 2 residents receiving services.

Inspectors wroteBased on observations of the physical environment, with Engineering Director (employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to equip corridors with firmly secured handrails on each side. This deficient practice had the potential to affect 2 out of 2 residents receiving services.

Inspectors wroteBased on observations of the physical environment, with Engineering Director(employee #13) and Safety Officer (employee #2) performed on 09/09/2024 through 09/10/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to maintain an effective pest control program . This deficient practice had the potential to affect 2 out of 2 residents receiving services.

Inspectors wroteBased on interview with administrator (employee #10) and review of facility policies and procedures, it was determined that facility failed to develop and implement a compliance and ethics program, with respect to a facility.

Inspectors wroteBased on interview with the facility human resources personnel (employee #11), it was determined that facility failed to offer behavioral health training to their personnel that provide services at the facility.