San Pedro Manor

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 8 residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's representative when staff reported a skin tear . This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 resident (Residents #12 and #92 ) reviewed for incontinent care, in that: 1. While providing incontinent care, CNA G made multiple passes with the same wipe while cleaning Resident #12's buttocks. 2. While providing incontinent care for Resident #92, CNA E did not separate Resident #92's labias to clean the meatus (urinary opening) This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 3 of 29 residents (Resident #6, #43, and #93) reviewed for palatable and appetizing food, in that: 1. The facility served Resident #6 meals that were cold. 2. The facility served Resident #43 meals that were cold 3. The facility served Resident #93 meals that were cold. These failures could place residents at risk for a diminished quality of life by not receiving food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility in that: 1. The facility failed to replace or clean dirty overhead ceiling vents in the main kitchen area. 2. The facility failed to clean a rusty overhead ceiling vent cover in the dish room. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #92 ) reviewed for infection control, in that: The facility failed to ensure CNA E used proper infection control while providing incontinent care for Resident #92. These deficient practices could place residents at-risk for infection due to improper care practices

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #92) reviewed for privacy, in that: CNA E and CNA F did not close completely Resident #92's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #8) reviewed for infection control, in that: The facility failed on 07-29-2025 when CNA D failed to wear a gown while caring for Resident #8 who had a surgical chest incision and required the use of PPE., In-addition there was no EBP sign posted outside or inside the resident's room or no PPE readily available for staff or visitors use. This failure placed residents at risk of transmission of communicable diseases, a decline in health status, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #1's electronic medical record did not contain complete and accurate documentation regarding whether his falls on 5/28/25 and 7/12/25 were witnessed by nursing staff or unwitnessed. This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the interdisciplinary team as to whether a resident fall was witnessed or unwitnessed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (3rd floor)community shower rooms in that: The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. 30 possible residents could use the 3rd floor shower room. This could affect all resident that shower in the 3rd floor shared shower and could result in infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #40) reviewed for accidents. The transportation driver failed to ensure Resident #40 was safely transferred onto the transportation van on 06/21/24 when he was picked up for dialysis. The resident sprained his foot when it got caught in the van gap where the ramp met the van. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that prohibit, prevent abuse, neglect and exploitation of residents for three of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting. 1. The facility failed to follow their policy to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. 2. The facility failed to follow their policy to report to the State Survey Agency when Resident #36 was found to have ant bites on her body. 3. The facility failed to follow their policy to report to the State Survey Agency when Resident #9 was given the wrong medications on 04/22/24. These failures could place residents at risk of lacking timely reporting of incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for three (Resident #40, Resident #36, and Resident #9) of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting. 1. The facility failed to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents # 57 and # 185) of 8 residents reviewed for infection control. Staff failed to don appropriate Personal Protective Equipment (PPE) while providing care to Resident #57, who had a colostomy, and Resident #185, who had a catheter. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 6 residents (Resident #8) reviewed for safe and functional equipment. The facility failed to ensure Resident #8's bed was in proper working condition. This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 1 of 1 facility kitchen and 1 (Resident #36) of 5 residents reviewed for pest control. 1. Resident #36 repored her bed was infested with ants and she had numerous bites to her arms and legs. 2. There were multiple gnats observed in the kitchen food preparation area, storage area room, dishwasher room and floor drain This failure could place residents at risk of a decreased quality of life and cross contamination of food.

Inspectors wroteBased on observation, interview and record review the facility failed to provide comfortable and safe temperature levels between a range of 71 to 81 degrees Fahrenheit for one of ten residents (Resident #2) reviewed for environment. The facility failed to ensure Resident #2's room remained at a comfortable temperature. This failure could place residents at risk of experiencing decreased comfort and could affect the well-being of residents.

Inspectors wroteBased on interview and record review, the facility to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other then the State mental health authority prior to admission for one of six residents (Resident #63) reviewed for Preadmission Screening and Resident Review (PASRR) screening . The Social Worker failed to ensure Resident #63's PL1 was accurate with the proper metal illness diagnosis when he was admitted . This failure could place residents at risk of not receiving specialized services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding, including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of four residents (Resident #19) reviewed for enteral feeding. The facility failed to ensure nursing staff provided g-tube (a tube into the stomach that delivers formula for nutrition) care for Resident #19 per physician orders. This failure could result in the spread of resident infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #9) reviewed for pharmacy services. LVN A failed to administer the correct physician ordered medication (Pantoprazole Sodium Delayed Release 40 mg tablet and Tramadol HcL 50 mg tablet), and she instead administered Alprazolam Oral Tablet 0.5 mg (anti-anxiety medication), and Hydrocodone-Acetaminophen 10-325 mg (narcotic pain medication), which was another resident's medication on 04/22/24. This failure could place residents at risk for significant medication errors and jeopardize the resident health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, the medical record was maintained on each resident that were complete and accurately documented for 1 of 4 residents (Resident #19) records reviewed for treatment documentation. The facility failed to ensure LVN F accurately documented Resident #19's g-tube (a tube into the stomach that delivers formula for nutrition) care. This failure could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. This failure could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 12/04/2023. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 12/4/2023 and ended on 12/22/2023. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that: CNA A did not change her gloves or wash her hands after touching Resident #2's privacy curtain, between change of gloves and, after providing incontinent care for Resident #2. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 4 residents (Resident #1) reviewed for medication administration. The facility failed to ensure Resident #1 received his scheduled Alprazolam Oral Tablet .5 MG in accordance with his physician's orders. This failure could place residents at risk of not receiving the therapeutic benefits of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a bag of shredded cheese past its use-by date in the walk-in cooler. 2. There were two containers of milk that had been opened that were without labels indicating the date they had been opened. 3. The dish machine failed to reach the proper temperature during the wash cycle. 4. [NAME] C was wearing jewelry on her hand while preparing food in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation and interview the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 1 facility. Residents' medical records were stored in an unlocked room on the 3rd floor that was being remodeled. Medical record sheets were out of their files and scattered on the floor in multiple places in the room. This failure could place resident identifiable information at risk of unauthorized use.

Inspectors wroteBased on observation, interview and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 1 of 19 Residents (Resident #72) reviewed for resident rights in that: LVN A stood while feeding Resident #72 on 05/09/2023 during the noon meal. This failure could affect residents who required assistance with eating and could contribute to feelings of poor self-esteem and decreased self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Residents #74) whose assessments were reviewed. Resident #74's Significant Change MDS dated [DATE], was coded to not be considered by the state level II PASRR while Resident #74 received PASRR services. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 4 waste receptacles in that: There were two waste receptacles filled with waste that did not have tight fitting lids and one waste receptacle was overfilled and could not be closed outside the facility. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.