San Luis Care Center
SAN LUIS CARE CENTER in NEWMAN, CA — inspection on August 8, 2024.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R41's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/24, located in the resident's EMR under the MDS tab indicated the facility assessed R41 to have a Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating R41 was cognitively alert.
Review of R41's Care Plan, located in the resident's EMR section titled Care Plans, revealed the resident had a care plan with revision date of 08/01/24.
The care plan identified the resident had focus for R41 was at risk for altered nutrition/hydration status and/or weight fluctuations.
Supplements: health shakes three times a day and multivitamins with minerals.
Review of care plan did not have any indication of R41 refusing weekly weights.
Interview on 08/08/24 at 11:40 AM with Licensed Vocational Nurse (LVN) 2 revealed they have weekly meetings with the Registered Dietician to discuss any nutrition concerns. LVN2 stated R41's last nutrition review was 05/31/24 and RD recommended multi vitamins, health shake and continue weekly weights. LVN2 stated they are responsible for ensuring R41's care plan was updated with all dietician recommendations. LVN2 stated R41 sometimes refuses weights but confirmed there was only one note from May 2024 through July 2024 indicating R41 refused to be weighed. LVN2 stated they were responsible for ensuring R41's care plan was updated with interventions for refusing weekly weights.
Interview on 08/08/24 at 12:04 PM with Director of Nursing (DON), revealed LVN2 was responsible for initiating R41's weekly weights and other nutrition interventions are implemented and entered on their comprehensive care plan. DON stated if a resident is refusing interventions and still triggering for weight loss then staff are to let the RD and Physician know so they can attempt to go over the risk verse benefits with resident.
055839
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055839 B.
Wing 08/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
San Luis Care Center 709 N Street Newman, CA 95360