San Marcos Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (C) Certified nurse aides. (iv) Resident census for 1 of 1 facility reviewed for posted nurse staffing. The facility failed to post nurse staffing as required from 12/19/2025 to 12/29/2025. This failure placed residents at risk of not knowing their rights to sufficient staffing. Record review of the facility's census (number of residents in the building) dated 12/29/2025 reflected 104. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: Manage Resident #1's diarrhea and urine when her MASD worsened causing her skin to be inflamed with erosions and severe excoriation (rubbing of the skin leading to abrasions or erosions) to her groin, buttocks, thighs, and axilla (arm pit) which consequently required treatment in the burn unit at the hospital from [DATE] - 07/17/25. Manage Resident #1's pain when her wounds were causing her excruciating pain in July of 2025 causing her to cry, moan, and groan during personal care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: Manage Resident #1's diarrhea and urine when her MASD worsened causing her skin to be inflamed with erosions and severe excoriation (rubbing of the skin leading to abrasions or erosions) to her groin, buttocks, thighs, and axilla (arm pit) which consequently required treatment in the burn unit at the hospital from [DATE] - 07/17/25. Manage Resident #1's pain when her wounds were causing her excruciating pain in July of 2025 causing her to cry, moan, and groan during personal care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for medications. The facility failed to administer three doses of insulin after Resident #1 was admitted on [DATE] due to pending delivery from the pharmacy. This failure could affect residents by putting them at risk of exacerbation of their health conditions and deterioration of their health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of one (Resident #1) of three residents reviewed for significant medication errors. The facility failed to administer three doses of insulin after Resident #1 was admitted on [DATE] due to pending delivery from the pharmacy. This failure could affect residents by putting them at risk of exacerbation of their health conditions and deterioration of their health.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed. The facility failed to notify the NP immediately when Resident #1 was admitted and they did not have his prescribed insulin. This failure could affect residents by putting them at risk of exacerbation of their health conditions and deterioration of their health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respect the residents' right to personal privacy of medical records for 3 of 8 Residents (Residents #95, #34, and #50) reviewed for privacy. The facility failed to ensure MA H protected confidential resident health care information of Residents #95, #34, and #50. This failure could place residents at risk of personal information being exposed to unauthorized persons.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 14 residents (Residents #75 and 450) reviewed for environment. The facility failed to ensure the room for Residents #75 and #450 did not possess a strong, foul odor due to Resident #75's behavior of urinating in places other than his toilet. This failure placed residents at risk of infection and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 5 of 8 residents (Residents #10, 71, 75, 449, and 450) reviewed for care plans. The facility failed to ensure the care plans for Residents #10, 71, 75, 449, and 450 included person-centered goals and interventions for activities. This failure placed residents at risk of not having their recreational and social needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 15 residents (Residents #49, #41, and #34) reviewed for ADLs. The facility failed to ensure Residents #49, #41, and #34 were provided nail care as documented in their plan of care and MDS. This failure could place residents at risk of scratches, infection, and poor self-esteem.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 12 residents (Residents #71 and #449) reviewed for activities. The facility failed to provide Resident #71 and #449 with activities from 08/13/24, 08/14/24, and 08/15/24. This failure placed residents at risk of not having their recreational and social needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. The cook failed to wear gloves while touching ready to eat food such as tortillas while making breakfast tacos on the breakfast tray service line. A container of sugar in the dry storage room was not sealed with an approximate 2-centimeter gap opening of the sugar container lid allowing for possible pest contamination. A 50 lb. bag of rice in the dry storage room was not sealed. The opening of the top of the bag was completely open to possible pest contamination. The temperature/sanitizer log for the dish machine was not completed, filled out, and up to date. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3 of 3 residents reviewed (Resident #49, #90, and #66) for medication administration, urinary catheter care, and wound care. as indicated by: 1. The facility failed to ensure MA H did not cross contaminate a medication cup and place medications in it for administration to Resident #49. 2. The facility failed to ensure nursing staff kept Resident #90's urinary catheter bag off of the floor. 3. The facility failed to ensure LVN G used proper infection control practices while providing wound care to Resident #66. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to assist residents in obtaining routine dental services to meet the needs of 2 of 12 (Resident # 13 and Resident # 79) reviewed for dental services. The facility did not assist Resident # 13 with obtaining dental services when her bottom denture broke. The facility did not assist Resident # 79 with obtaining dental services when he reported his dentures had been left in Mexico. This deficient practice could affect residents by placing them at risk of not receiving necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being which could result in a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #1) of four residents reviewed for accidents hazards, in that: The facility failed to ensure all rough edges of Resident #1's bed frame were covered, resulting in a laceration to his left leg during a transfer. This failure could place residents at risk of pain, bruising, or skin tears.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 8 residents (Resident #57) reviewed for call lights in that: Resident #57 was observed in his room with the call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one of 32 residents (Resident #32) reviewed for activities. Resident #32 was receiving no activities in the facility. This failure placed Resident #32 at risk of boredom, depression, and diminished quality of life.