El Centro Post-Acute Care

In the surveyor’s words

From the most serious findings on record at El Centro Post-Acute Care, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 3, 2024

  Based on observation, interviews and record reviews, the facility failed to protect the resident ' s (Resident 1) rights to be free from sexual abuse when Resident 2 ' s wandering behavior was not assessed, and he was found in Resident 1 ' s bed engaging in sexual act. As a result, Resident 1 and Resident 2 engaged in sexual encounter which was not consensual and Resident 1 required hospitalization for evaluation of sexual assault. Findings: On 6/9/22 at 2:24 P.M., an unannounced onsite at the facility was conducted related to a facility reported resident abuse. On 6/9/22, a review of Resident 1 and Resident 2 ' s record was conducted. 1. […]

• No harm, potential for more than minimal, widespreadF814Sep 12, 2024

  Based on observation, interview, and facility policy review, the facility failed to dispose of garbage and refuse properly, affecting 1 of 2 trash dumpsters and 2 of 2 recycle dumpsters. Specifically, a trash dumpster was missing a lid and the recycle dumpsters were full to the point of being unable to be covered. The deficiency had the potential to affect all residents residing in the facility. Findings included: A facility policy titled, Waste Management, dated 2001, indicated, The facility will maintain the outside dumpster area in a manner that minimizes health hazards, pest infestations, and environmental contamination, ensuring all waste is properly disposed of in accordance with local, state, and federal guidelines. The policy indicated, 1. Dumpster Maintenance: included a. […]

• No harm, potential for more than minimal, widespreadF880Sep 12, 2024

  Based on observation, interview, record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff were fit tested for a respirator required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents, which had the potential to affect all residents that resided in the facility, and failed to use proper hand hygiene during catheter care for 1 (Resident #221) of 1 resident observed for catheter care. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF801Apr 29, 2021

  Based on observation, interview, and record review the facility failed to employ a qualified Dietetic Services Supervisor or Registered Dietitian to effectively manage and provide oversight of the day-to-day functions of the food and nutrition services department; and monitor resident nutrition care, which led to: 1) Seven residents with severe weight loss of greater 7.5% in a 30 day period who were not weighed for 45 days (cross reference 692), 2) Three residents on enteral feedings were not regularly assessed by an RD, according to facility policy (cross reference 692), 3) The lack of evaluation of dietary staff competency in carrying out kitchen tasks and oversight of food safety and sanitation practices (cross reference 802 and 812), 4) The overall assessment of food production in… […]

• No harm, potential for more than minimal, widespreadF802Apr 29, 2021

  Based on observation, interview, and record review the facility failed to ensure a food and nutrition services staff had the competencies required to properly carry out the food safety and sanitation duties in the kitchen according to standards of practice. This failure led to deficient practices in the kitchen that had the potential to negatively affect the nutrition and health status of the 43 residents in the facility. (cross reference 801 and 812) Findings: On 8/5/20 at 9:39 AM, an observation and interview was conducted with food service worker (FSW 1) and the Cook (CK) in the facility kitchen. FSW 1 stated she was a dishwasher. CK stated FSW 1 was hired a week ago. CK stated she trained FSW 1 on the dishwasher position and other duties in the kitchen. […]