Eliseo

In the surveyor’s words

From the most serious findings on record at Eliseo, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 25, 2024

  Based on observation, interview and record review, the facility failed to evaluate the effectiveness of fall prevention interventions, need for additional action, and/or attempt to mitigate envionmental modifications preferred by the resident that presented a risk to safety for 1 of 3 sampled residents (Resident 1) reviewed for accidents and hazards. Resident 1 experienced harm when they fell out of bed and sustained a neck fracture. This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . Review of the facility Fall Prevention Program policy and procedure dated 03/2023 showed the facility used a standardized risk assessment for determining a resident's fall risk. […]

• No harm, potential for more than minimal, widespreadF880Jul 6, 2026

  Based on interview and record review, the facility failed to have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. This failure placed residents, visitors and staff at an increased risk of waterborne illnesses. Findings included.Review of the facility provided water management program dated 11/02/2024 and updated 07/02/2026 failed to show the following items were in place: 1. Identify adequate program team members (infection preventionist was not included in the plan). 2. Accurately describe building water systems.3. Identify areas Legionella or other waterborne pathogens could grow/spread. 4. Identify control measures used to monitor for the presence of pathogens. 5. […]

• No harm, potential for more than minimal, widespreadF761Jun 5, 2024

  Based on observation, interview, and record review, the facility failed to ensure proper labeling of insulins in 1 of 4 medication carts (700-hall Medication Cart) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective medications, and a diminished quality of life. Findings included . Observation on 06/05/2024 at 9:22 AM showed two multi-dose insulin pens with no open date or expiration date in the 700-hall medication cart. During an interview on 06/05/2024 at 9:35 AM, Staff N, Licensed Practical Nurse, stated insulin pens should be dated when opened and there were two undated pens in the 700-hall medication cart. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2024

  Based on observation and interview, the facility failed to ensure foods were sanitarily stored in the kitchen and 3 of 4 resident refrigerators (Ocean, Mountain, and Narrows Dining) when reviewed for kitchen. These failures placed residents at risk of consuming contaminated foods, avoidable foodborne illness, and a diminished quality of life. Findings included . Observation on [DATE] at 9:38 AM showed the facility walk-in refrigerator had four bags of raw chicken sitting in approximately one inch of bloodied water, one container of minced garlic without date label, a container of pudding with no date, a package of bacon with a use by date of ,d+[DATE], a salad uncovered, undated, and severely dried, four trays of raw fish on a rack uncovered and undated, and a container of sliced tomato… […]

• No harm, potential for more than minimal, patternF561Jul 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were given showers based on their choices for 5 of 8 sampled residents (Residents 5, 65, 9, 36 and 11) reviewed for choices and unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, feeling unclean, and diminished quality of life. Findings included.Resident 5Review of the electronic health record (EHR) showed Resident 5 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (when a blood clot disrupts blood flow to the brain and causes brain cell death), dementia, and disorder of psychological development (childhood disorder affecting cognitive, social, emotional, speech and motor skills). […]