San Luis Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#60) of three residents reviewed for abuse were kept free from abuse out of 34 sample residents. Specifically, the facility failed to protect Resident #60 from sexual abuse by Resident #48.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two out of two units. Specifically, the facility failed to: -Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers performed hand hygiene while cleaning resident rooms;-Ensure housekeepers cleaned high touch surface areas; and,-Ensure dwell times (time needed to kill bacteria) were followed during resident room cleaning.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.