San Luis Care Center

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

Emergency Preparedness Deficiencies

Develop a communication plan.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

The initial comments (ID Prefix Tag # K 000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one-story wood-frame structure, Type V (111) construction, without a basement. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. There is a dry-pipe system that protects the attic space. The facility was surveyed on July 10, 2024, for compliance with fire safety requirements using the National Fire Protection Association (NFPA) Life Safety Code, NFPA 101, 2012 edition, Chapter 19, Existing Facilities; the NFPA Health Care Facilities Code, NFPA 99, 2012 edition; and referenced standards. The facility will meet these requirements upon completion of an approved Plan of Correction. Deficiencies were discussed with the Maintenance Director at the time of the survey and again during the exit conference.NOTE: Existing life safety features that meet the requirements for new construction at the time of licensure or certification shall be maintained and not be diminished. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) Fire Doors report (annually)(80 5.2): Not Done2) Resident Room 309 not latching3) 200 hall does double fire doors not latchingNFPA 101, 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.NFPA 80, 5.2 Inspections.5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.5.2.15.3 Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door ' s proper emergency function, the following actions shall be performed:(1)The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.(2)The door shall be tested to ensure emergency operation and closing upon completion of the repairs... Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) The Oxygen Trans-filling room needs mechanical ventilation within 12" of the floor.NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.NFPA 99 11.5.2.3.1Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility where in patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures.NFPA 99 9.3.7.5.3.4Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system.This deficiency could affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

A recertification survey with complaint #CO36384 was completed on 6/17/24 to 6/19/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 6/17/24 to 6/19/24. Six deficiencies were cited. Based 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 pla.. Based on record review and interview, the facility failed to develop and maintain an up to date emergency preparedness training program that aligns with the facility ' s specific individualized emergency preparedness progra.. Based 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, m.. Based on record review and interviews, the facility failed to develop and implement emergency preparedness policies and procedures, based on the facility' s emergency plan, risk assessment and communication plan, which were revie.. Based on record review and interviews, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and was reviewed and updated annually. &nbsp.. Based on record review and interviews, the facility failed to develop and maintain an up-to-date emergency preparedness training and testing of the emergency preparedness plan (EPP) that was based on the facility ' s emerge.. Based 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... Based 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 .. Based on record review and interviews, the facility failed to have a complete emergency preparedness communication plan.Specifically, the facility failed to have a complete communication plan that included all contact information for.. Based on record review and interviews, the facility failed to have an annual review of the complete emergency preparedness plan (EPP). Specifically, the facility failed to have an annual review of the EPP. Findings in.. Based 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.. Based 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.Specifical..