San Pedro Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 17, 2024

  Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 12/04/2023. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 12/4/2023 and ended on 12/22/2023. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. […]

• Immediate jeopardy, isolatedF692Jun 27, 2022

  Based on observation, interview, and record review the facility failed to ensure that acceptable parameters of nutritional status were maintained for 1 of 7 Residents (Resident #1) reviewed for weight loss. The facility failed to ensure Resident #1's significant weight loss was addressed per policy. Resident #1 lost over 30 pounds in a 2-month period. Weekly weights, and appropriate interventions were not made until after surveyor entrance on 6/22/2022. These failures resulted in an Immediate Jeopardy (IJ) on 6/24/2022 at 5:00 p.m. […]

• Actual harm, patternF600Dec 2, 2022

  Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #4) reviewed for abuse. 1. The facility failed to protect Resident #4 from being hit by Resident #5 with a walking stick on his right hand on 10/31/22. 2. The facility failed to protect Resident #4 from being fearful (psychosocial harm) of Resident #5 from 10/31/22 through 11/10/22 when Resident #4 filed a grievance. These failures could place residents at risk for continued abuse, undetected abuse, neglect and/or decline in feelings of safety and well-being; and psychosocial harm. Findings were: 1. […]

• Actual harm, isolatedF689Jun 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #40) reviewed for accidents. The transportation driver failed to ensure Resident #40 was safely transferred onto the transportation van on 06/21/24 when he was picked up for dialysis. […]

• Actual harm, isolatedF689Jan 23, 2023

  Based on observation, interview and record reviews the facility failed to the ensure the resident received assistance devices to prevent accidents and the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance for 2 of 5 Residents (Resident #1 & Resident #2) whose records were reviewed for falls. 1. Resident #1 had 4 falls within 24 hours upon admission related to nursing staff not providing Resident #1's fall history through report, lack of staffing and staff not initiating appropriate safety interventions to keep Resident #1 as safe as possible. As a result, he sustained multiple fractures. 2. Resident #2 had a history of falling out of his wheelchair. […]