El Centro Post-Acute Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and provide a safe, home-like environment when: 1. Resident rooms located on Station 1 were in need of repair for five of 20 rooms (Residents 54,118, 119, 122, and 137); and2. Resident rooms located on Station 2 were in need of repair for four of 20 rooms (Residents 5, 20, 51, and 90). These failures had the potential for residents to feel undervalued and unappreciated.2a. A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and cerebral infarction (an area of brain tissue death caused by a lack of blood flow and oxygen). On 1/6/26 at 8:19 A.M., an observation and interview was conducted with Resident 20 while inside the resident's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, nonhazardous environment when:1. A bathroom for one of six residents (Resident 122), had a loose toilet seat, that was not tightened down and moved from side to side; and2. Hazards were identified in two of three resident shower rooms (Shower rooms [ROOM NUMBERS] ). These failures had the potential for Resident 122 to become unbalanced and fall while using the bathroom and for residents using Station 1 and Station 2's shower room to cut, puncture, or injure themselves from the shower stall hazards. On 1/06/26 at 3:09 P.M., an observation and interview was conducted with Certified Nursing Assistant (CNA) 4 of shower room [ROOM NUMBER] (located by room [ROOM NUMBER]). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow professional standards for food service safety regarding storage when expired fish was found in a walk-in refrigerator. This failure had the potential to spread foodborne illness. On 1/6/26, at 8:30 A.M., a concurrent observation and interview was conducted with the Dietary Supervisor (DS) during an inspection of the walk-in refrigerator. A tray of fish covered with plastic was found labeled with an expiration date of 1/5/26. The DS stated this should have been discarded because it was expired. A facility policy titled Food Storage, dated 8/29/23, indicated that .any expired or outdated food products should be discarded .

Inspectors wroteBased on observation and interview, the facility failed to implement and maintain infection control standards of practice when: Two of three shower rooms were found with black residue on the grout between the tiles. Resident 89's nebulizer tubing and mask were not discarded and changed weekly. These deficient practices had potential risks for residents and staff to contract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity while assisting with a meal for one of three residents (Resident 70), by standing over the resident reviewed for Resident Rights. This failure had the potential for Resident 70 to feel overpowered, rushed, and undignified.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan related to monitoring an anticoagulant (blood thinner) for one of nine residents (Resident 42) reviewed for care plans. This had the potential to cause negative side effects and compromise Resident 42's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate a Nursing Standards of Practice during administration of medications via a gastrointestinal tube (G-Tube, a surgically inserted tube going into the stomach to provide nourishment, hydration, and medication when someone is unable to swallow safely on their own) for one of two residents (Resident 72) reviewed for G-Tube feeding. This failure had the potential for harm, when placement of the G-tube was not checked prior to medication administration, administering the crushed medications together, and using a syringe plunger to administer the medication instead of gravity, potentially causing too much pressure in the flexible tube, resulting in an implosion of the internal G-tube.(Cross reference F-759)

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring was provided for one of five sampled residents (Residents 42) receiving anticoagulant (blood thinner) medication. This had the potential to cause harm and compromise Resident 42's health and safety if signs and symptoms went undetected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent during a random medication pass observation process for one of four residents (Resident 72). Resident 72 had four medications administered incorrectly. The facility's medication error rate was 13.79 percent. As a result, there was the potential for the four medications to become ineffective when crushed, combined, and administered together. (Cross Reference F-658 and F-842)Resident 72 was admitted to the facility on [DATE], with diagnoses which included hemiplegia following cerebral infarction affecting the right side (stroke with weakness on the right extremities) and dysphagia (difficulty swallowing), per the facility's admission Record. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a medication order was accurately documented for one of ten sampled residents (Resident 72) when a medication taken by mouth was ordered for a patient who receives medication via a gastronomy-tube (G-Tube - tube placed through the belly directly into the stomach to deliver liquid food, medicine, and fluids when someone can't eat enough by mouth). This failure had the potential for Resident 72 to be administered medications via the wrong route.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer pain medication for the appropriate pain scale as indicated by the physician ' s orders for one of two residents (Resident 1) reviewed for pain management. This deficient practice had the potential to cause Resident 1 further discomfort and pain.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to dispose of garbage and refuse properly, affecting 1 of 2 trash dumpsters and 2 of 2 recycle dumpsters. Specifically, a trash dumpster was missing a lid and the recycle dumpsters were full to the point of being unable to be covered. The deficiency had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff were fit tested for a respirator required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents, which had the potential to affect all residents that resided in the facility, and failed to use proper hand hygiene during catheter care for 1 (Resident #221) of 1 resident observed for catheter care.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 1 was accurate for 3 (Resident #37, #91, and #71) of 5 sampled residents reviewed for PASRR.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) was completed accurately for 2 (Resident #60 and Resident #118) of 24 sampled residents reviewed for accurate assessments.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a physician's order for treatment of a diabetic ulcer was obtained for 1 (Resident #43) of 2 residents reviewed for skin conditions.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure physician ordered medications were available for 2 (Resident #75 and Resident #171) of 6 residents reviewed for pharmacy services.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure pharmacy recommendations were followed up on timely for 1 (Resident #82) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure an as-needed (PRN, pro re nata) order for psychotropic medication specified the duration of use for 1 (Resident #82) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate less than 5 percent (%). The facility had 2 medication errors out of 28 opportunities, affecting 2 (Resident #3 and Resident #171) of 6 residents reviewed during the medication administration task, resulting in a medication error rate of 7.14%.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a significant medication error did not occur for 1 (Resident #93) of 6 residents reviewed for unnecessary medications. Specifically, facility staff failed to follow a physician's order to hold losartan potassium and metoprolol tartrate (medications used to treat high blood pressure) when the resident's systolic blood pressure (SBP, the top number in a blood pressure reading) was less than 120 millimeters of mercury (mmHg).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to have a physician's order for hospice services for 1 (Resident #221) of 2 residents reviewed for hospice services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident ' s right was honored when one of 3 residents was not allowed to have a visitor after a fall incident (Resident 6). This deficient practice had the potential for the resident to have feelings of isolation, anxiety (feeling of fear, dread, and uneasiness) and/or sadness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the tube feeding (the amount of formula) order on the Medication Administration Record (MAR) was the same as the physician's order for one of three sampled residents (1). As a result, there was a potential for Resident 1 to receive an incorrect tube feeding amount.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to protect the resident ' s (Resident 1) rights to be free from sexual abuse when Resident 2 ' s wandering behavior was not assessed, and he was found in Resident 1 ' s bed engaging in sexual act. As a result, Resident 1 and Resident 2 engaged in sexual encounter which was not consensual and Resident 1 required hospitalization for evaluation of sexual assault.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident ' s (Resident 2) wandering behavior and develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) of Resident 2's wandering behavior. As a result, the lack of a resident centered care plan with specific interventions to reduce wandering behavior had the potential for Resident 2 to enter the rooms of other residents without permission. In addition, Resident 2 was found in another resident's room engaging in a sexual act.

Inspectors wroteBased on observation and interview the facility failed to adequately store medications behind a locked door. This failure had the potential to result in resident harm, for approximately 20 residents in Hallway 1, through accidental ingestion of unprescribed medications without staff awareness or supervision. On 10/25/23 at 11:40 A.M. and at 12: 21 P.M. an observation was made of an unlabeled door noted to be ajar and not completely closed. Upon opening the door, the room was noted to have over the counter, non-prespricption medications stored on open shelves, as well as a locked refrigerator and three tackle boxes sealed with zip-tie closures. The door did not self-close. An interview was held with LN 1, on 10/25/23 at 12:23 P.M., regarding the unlocked door. LN 1 demonstrated opening the door and letting it close, and stated that the door did not close all the way. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure that staff followed proper hand washing technique during a meal service for 7 residents. This failure had the potential to spread germs and cause infections among the residents. On 10/25/23 at 12:09 P.M., the following observations were made during meal service on Hallway 1. CNA 1 was seen leaving a resident room and walking to the meal delivery cart in the hallway. CNA 1 selected and held resident ' s meal tray and delivered to resident room [ROOM NUMBER]. CNA 1 then returned from resident room [ROOM NUMBER] to the meal tray cart and selected and held another tray. No hand hygiene was observed. CNA 2 was seen leaving resident room [ROOM NUMBER]. CNA 2 selected and held a tray from the meal delivery cart, and delivered to another resident room. No hand hygiene was observed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans related to: 1. Smoking, for one of one resident (2) reviewed for smoking, 2. Oxygen use, for three of three residents (24, 4, and 42) and 3. Indwelling catheter for one of three residents (25) reviewed for urinary catheter care. This failure had the potential to affect residents medical needs and care.

Inspectors wroteBased on observation, interview, and record review, the facility did not serve food in an appealing manner for five of five residents (23, 28, 9, 47, & 50) reviewed for food preferences. In addition, food concerns were identified during the confidential general resident council meeting for eight of 11 confidential residents. This failure had the potential for residents to suffer from a lack of daily nutritional requirements, because the food was not palatable.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure potentially hazardous foods were clearly labeled with their use-by date. This failure had the potential to cause the food to develop pathogens that contaminate food and may cause foodborne illness if consumed.

Inspectors wrote5) Resident 10 was readmitted to the facility on [DATE], with diagnoses to include muscle wasting and atrophy (decrease in muscle mass due to extended immobility). An MDS (Minimum Data Set - an assessment tool), dated 1/27/21, indicated Resident 10 had a BIMS (Brief Interview for Mental Status; an assessment tool) score of 99 (unable to assess mental status). On 5/3/21 at 1:07 P.M., an observation of Resident 10 was conducted. Resident 10 was in bed, lying on his left side, and the head of the bed was elevated. A review of Resident 10's medical record was conducted on 5/3/21. A physician order, dated 11/5/20, indicated to Cleanse with NS (normal saline) & pat dry to SC (sacro-coccygeal; tail-bone area) stage 4 apply Santyl (a medication to treat wounds) & cover with Island (a type of dressing) drsg (dressing) daily & as needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an Antibiotic Stewardship Program. This failure had the potential to increase the risk of residents developing antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to implement a physician's order related to: a. medication administration, and b. monitoring for side effects of a medication for one of one sampled residents (2). This failure had the potential to affect the resident's physical and emotional needs and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide podiatry services for one of one residents (25) reviewed for Activities of Daily Living (ADL). This failure had the potential to cause pain and possible infection if the overgrown toenails damaged the resident's skin.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide restorative nurse's aide (RNA) services as ordered for one of one resident (10) reviewed for RNA services. This failure had the potential for Resident 10's contractures to worsen.

Inspectors wrote2. Resident 4 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease, too much oxygen [O2] could cause oxygen buildup, due to high carbon dioxide content in the blood that leads to drowsiness and possible death), per the facility's Record of Admission. A review of Resident 4's history and physical (H&P), dated 3/4/21, indicated Resident 4 had the capacity to understand and make decisions. On 5/3/21 at 2:41 P.M., an observation and interview of Resident 4 was conducted. Resident 4 was in bed, using oxygen (O2) via a concentrator (a device that concentrates the oxygen), running at 4 liters per minute (LPM) via nasal cannula (NC - tubing to deliver oxygen). Resident 4 stated she needed the oxygen when she was in bed, and but did not need it when she was up in the wheelchair. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for one of three residents (25) reviewed for catheter care. This failure had the potential to result in a lack of treatment and services for a resident with an indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. Fifteen medication errors out of 29 opportunities were identified during medication (med) administration, when nursing: 1. Administered seven crushed medications all at once (instead of individually) via the PEG (Percutaneous endoscopic gastrostomy tube - a tube placed directly into the stomach for the administration of food, fluids, and medications) tube to Resident 37, 2. Administered four crushed medications all at once (instead of individually) via PEG tube to Resident 18, and 3. Omitted four oral medications for Resident 304. This failure resulted in a medication error rate of 51.72%

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications (med/s) were administered correctly when: 1. Licensed nurse (LN) 2 crushed seven medications and administered all at once (instead of individually), via PEG tube (Percutaneous endoscopic gastrostomy tube - a tube placed directly into the stomach for the administration of food, fluids, and medications) to Resident 37; 2. LN 2 crushed four medications and administered all at once (instead of individually), via PEG tube to Resident 18. 3. LNs checked the medication label and expiration date of Resident 304's medications. These failures could cause harm to the residents due to unsafe administration of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Medications (med) were labeled with an expiration date for one resident (304), and an opened bottle of normal saline was dated and labeled for one of three medication carts; 2. Expired bottles of iron supplements were co-mingled with current medications readily available for use; 3. Expired biologicals (glucose test solutions, glucose test strips, iodine swab sticks, nasal swabs, and laboratory [lab] tubes) were co-mingled with treatment supplies in two of three medication carts; and 4. The temperature was monitored for one of two medication storage rooms. These failures had the potential for residents to receive expired medications, and affect the efficacy of medications and effectiveness of treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an alternative weekly meal menu for four of four residents (23, 50, 9, & 47) reviewed for food preferences. This failure had the potential for residents to suffer from a lack of daily nutritional requirements because the food was not appealing and there were no alternate choices.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA- checks on standards and quality of care) Committee had the Medical Director or designee in attendance during the Quality Assurance and Performance Improvement (QAPI) meetings. The lack of participation of the medical director or designee in QAPI meetings had the potential risk to not identify care issues/services that could affect the quality of life of the residents.