Inspection·January 18, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interviews, record review, and document review, the facility failed to notify the state designated authority when a significant change in status assessment was completed for 1 (Resident #7) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A review of Resident #7's Face Sheet, revealed the facility admitted the resident on 06/01/2009, with diagnoses of malignant neoplasm of colon, anxiety, psychotic disorder with hallucinations, and major depressive disorder. A review of a document addressed to Resident #7 from the State of California - Health and Human Services Agency Department of Health Care Services, dated 01/28/2019, revealed Resident #7's Level II PASARR evaluation suggested the resident was best served in a skilled nursing facility bed with access to services. A review of Resident #7's medical record revealed a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2023, was signed as being completed on 12/26/2023. A review of Resident #7's medical record revealed no evidence to the state designated authority was notified when the resident had a significant change in status assessment completed. During an interview on 01/18/2024 at 1:40 PM, the Director of Nursing stated she would expect a rescreen to be completed if a resident who received Level II services had a significant change in status assessment completed. During an interview on 01/18/2024 at 1:54 PM, the Acting Administrator stated she would expect Resident #7 to have a rescreen PASARR submitted when the significant change in status assessment was completed. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056189 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)