San Remo

Inspectors wroteBased on observation, interview and record review the facility failed to incorporate the recommendations from the PASRR (Pre-admission Screening and Resident Review) program under Medicaid and initiate services within 30 days after the date that the services are agreed upon in the IDT meeting, to ensure that individuals with mental illness or intellectual developmental disabilities receive the care and services they need in the most appropriate setting for 1 of 1 residents (Resident #1) reviewed for PASRR services. The facility did not submit a request for approval for Resident #1's Orthotic shoes in the LTC Online Portal within 20 business days after the date of Resident #1's IDT meeting on 04/22/26. [...]

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 safety. The facility failed to ensure that expired items in the refrigerator were removed. This deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for food-borne illnesses. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had a right to privacy and confidentiality of his or her personal and medical records and treatment for nine (Residents #1, #12, #23, #42, #45, #73, #81, #119, and #130) of eighteen residents reviewed for privacy and confidentiality.1. The facility failed to ensure LVN I secured Residents #1, #12, #23, #42, #45, #81, #119, and #130's medical information before leaving her nurse's cart on 02/18/2026. 2. The facility failed to ensure LVN I closed Resident #45's door while checking his blood sugar and administering his insulin on 02/18/2026.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 20 resident rooms (Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) observed for cleanliness. The facility failed to ensure Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 were thoroughly cleaned and sanitized. This facility failure could place residents at risk of living in an unclean and unsanitary environment, leading to a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from any physical or chemical restraints imposed for purposes of discipline or convenience, and that not required to treat the resident's medical symptoms for 1 of 4 residents (Resident #73) reviewed for abuse and neglect. The facility failed to ensure Resident #73 was not sedated with a medication prescribed for a condition or diagnosis not listed in the resident's EHR. This deficient practice could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 6 of 18 residents (Resident #20, #45, #78, #106, #112 and #113 ) reviewed for care plan. 1. The facility failed to ensure Resident #20's care plan reflected a plan of care for the resident's use of a weighted spoon when eating his meals. 2. The facility failed to ensure Resident #45 was care planned for diabetes mellitus and hypertension. 3. The facility failed to ensure Resident #78 was care planned for his indwelling catheter. 4. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for four (Residents #78, #84, #104, and #106) of twelve residents reviewed for care plans revision. The facility failed to ensure the care plan for Residents #78, #84, #104, and #106 were reviewed and revised after each comprehensive and quarterly assessment. This failure could place the residents at risk of care and needs not being met.

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 three of four residents (Residents #1, #42, and #112) reviewed for feeding tube management.1. The facility failed to ensure Resident #1 had an order to check the placement for the resident's g-tube on 02/18/2026.2. The facility failed to ensure Resident #112 had an order to check the placement of the g-tube and to check the residual on 02/18/2026.3. The facility failed to ensure Resident #42 had an order to check the residual on 02/18/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess the resident for the risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails prior to installation for 5 of 8 residents (Resident #1, Resident #5, Resident #42, Resident #73, Resident #87) reviewed for grab/assist bars. 1. The facility failed to have evidence of informed consent for Resident #1, Resident #5, Resident #42, Resident #73, and Resident #87 for grab/enabler bars to be placed on the bed. 2. The facility failed to have evidence of assessment for Resident #5, Resident #73, and Resident #87, for risk of entrapment and ability to safely use the grab/enabler bars. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for nine of eighteen residents (Resident #27, #29, #69, #78, #82, #84, #90, #112, and #114) reviewed for labelling of drugs and biologicals. The facility failed to ensure Resident #27's zinc oxide was not left on top of the resident's drawer on 02/17/2026. [...]

Inspectors wroteBased 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 three of fifteen residents (Residents #42 and Resident #112) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene, changed her gloves, and wore a gown during Resident #112's incontinent care on 02/17/2026.2. The facility failed to ensure CNA F and CNA G wore gowns when Resident #112, who was on enhanced barrier precautions due to having a g-tube, was transferred to his wheelchair on 02/17/2026. 3. The facility failed to ensure CNA F wore a gown when fixing Resident #112's beddings on 02/17/2026. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #113) of eight residents reviewed for resident rights. The facility failed to treat Resident #113 with dignity and promote enhancement of his quality of life when the resident was not provided privacy for his nephrostomy bags (collects urine from the urinary bladder) on 02/17/2026. This failure could place residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one of six residents (Resident #86) reviewed for the resident rights. The facility failed to ensure the call light system in Resident #86 room was in a position that was accessible to the residents on 02/17/26. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for two (Resident #23 and Resident #106) of eight residents reviewed for accuracy of assessments.1. The facility failed to ensure Resident #23's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had a tracheostomy.2. The facility failed to ensure Resident #106's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter. This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.

Inspectors wroteBased on observations, interview and record reviews the facility failed to implement care plans for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and was developed within 48 hours of the resident's admission for one of two residents (Resident #117) reviewed for baseline care plans. The facility failed to ensure a sufficient baseline care plan was completed for Resident #117 that identified the Pleural Effusion (Pleural effusion, commonly called fluid on the lungs) care needed within 48 hours of the resident's admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Residents #12) of four residents reviewed for quality of care. The facility failed to ensure that Resident #12's ulcer to the right lateral ankle was covered as per physician order on 02/19/2026. This failure could place the residents with ulcers at risk for worsening of the existing ulcers and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for two (Resident #42) of four residents reviewed for pressure ulcers. The facility failed to ensure that LVN A did not use only one gauze to pat dry Resident #42's pressure ulcer to his sacrum as well as the surrounding skin of the pressure ulcer on 02/18/2026. This failure could place the residents with pressure ulcers at risk for worsening of the existing pressure ulcers and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 of 6 residents (Resident #25 and #101) reviewed for accident prevention. The facility failed to ensure Resident #25's used syringes were safely discarded. The facility failed to Resident #101's bed was in a low position for fall prevention per the care plan. This failure could prevent the residents from having an environment that was free from hazards.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of six residents (Resident #36 and #82) reviewed for respiratory care. The facility failed to ensure Resident #36 and #82's breathing treatment masks were properly stored in a bag when not in use on 02/17/26. The facility failed to ensure Resident #36's nasal canula was properly stored in a bag when not in use on 02/17/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two of eight residents (Resident #45 and Resident #118) reviewed for pharmaceutical services.1. The facility failed to ensure LVN I clicked Y next to each of Resident #118's medication being prepared or was about to administer on 02/18/2026.2. The facility failed to ensure LVN I checked Resident #45's blood pressure before administering Resident #45's anti-hypertensive medication on 02/18/2026. These failures could place residents at risk of not receiving medications as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 1 of 4 residents (Resident #73) reviewed for unnecessary medications. The facility failed to ensure Resident #73's medical chart and drug regimen were reviewed at least monthly. This failure could place residents at risk for receiving medications without a corresponding diagnosis, informed consent, or reviewed for gradual dose reduction.

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 for 1 of 1 kitchen reviewed. 1. The facility failed to seal open items in plastic bags in the dry storage pantry and freezer according to guidelines. 2. The facility failed to ensure that expired items in the dry storage pantry and refrigerator were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on 12/03/24 at 9:21 AM, revealed that in the dry storage area, there was one box of 1 lb. box of Monarch brand baking soda that was open, one 2 1b. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the right to receive written notice, including the reason for the change, of a room change before the change was made for 1 of 1 resident (Resident #92) reviewed for notification of room change. The facility failed to ensure Resident #92 received written notice prior to her room change. This failure could place residents at risk for being displaced without notice and/or reason and not allow the resident the right to see the new location and ask questions about the move.

Inspectors wroteBased on interviews, and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #82) of five residents reviewed for PASARR services. The facility failed to refer Resident #82 for a PASARR level II evaluation to the State-designated authority. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #58) of three residents observed for catheters. 1. CNA D failed to clean Resident #58's suprapubic catheter site and catheter during a bath. 2. The facility failed to ensure Resident #58 had a securement device to keep his catheter from pulling. This failure could place residents at risk of cross-contamination and development of urinary tract infections.

Inspectors wroteBased on observation, interviews, 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 one (Resident #58) of five residents observed for infection control. 1. The facility failed to ensure CNA D wore the appropriate PPE and performed hand hygiene while bathing Resident #58. These failures placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services in that: The facility failed to ensure employees with keys used to access to controlled medication did not share those keys without first properly counting the inventory of the controlled medications. LVN A shared the keys to her medication cart, which contained a separately locked compartment for controlled medications, with LVN B during the course of their shift. LVN A later discovered 30 tablets of Oxycodone (a controlled narcotic drug), belonging to Resident #1, was missing from her medication cart at the end of her shift. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for one of four residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's room was clean. This failure could place residents at risk for unsanitary living conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for one of three residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan to address Resident #1 wanted to be independent and change his own brief This failure could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing.

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 safety in the facility's only kitchen. 1. The facility failed to ensure food items and clean dishes were kept away from airborne contaminants. 2. The facility failed to ensure food items were properly labeled and dated in accordance with professional standards. These failures could place all residents who received food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 2 of 4 medication carts (800 Hall and 600 Hall) reviewed for drug storage. LVN A left 2 medication carts (800 Hall and 600 Hall) in the [NAME] Unit, unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications.

Inspectors wroteBased 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 and to help prevent the development and transmission of communicable diseases and infections for one (#138) of 3 residents reviewed for infection control. CNA D failed to perform hand hygiene and put on the appropriate PPE, such as gloves and a gown, prior to entering and exiting Resident #138's room who was in insolation due to a diagnosis of clostridium difficile (infectious germ that can be transmitted from person to person). This failure caused potential for the spread of infection.