Inspection·March 13, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to conduct an assessment of self-administration of medications, obtain a doctor's order, and ensure a care plan was developed for one of 5 sampled residents (Resident 30). Residents Affected - Few This failure had the potential to increase the risk for medication errors which could compromise the safety and well-being of Resident 30. Findings: Resident 30 is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included unspecified asthma with acute exacerbation (a sudden worsening of asthma symptoms, where the specific type of asthma is not specified, requiring immediate medical attention). On 3/10/25 at 10:15 a.m., in room [ROOM NUMBER], Resident 30 was observed holding in her hand, an inhaler medication. Resident 30 stated that she was a retired physician and aware of how to self-administer her own inhaler medications. On 03/10/2025 at 10:25 a.m., a concurrent interview and record review was conducted for Resident 30 with licensed nurse (LN) 4. LN4 confirmed there were no physician orders for Resident 30 to keep inhaler medication at the bedside. LN4 confirmed there were no IDT notes which included documentation of an assessment of self-administration of medication for Resident 30. On 3/11/2025 at 4:10 p.m., a record review was performed for Resident 30. No care plan for self-administration of bedside medication was found in the electronic medical record (EMR) or in patient's paper chart. On 3/11/2025 at 4:20 p.m., a concurrent interview and record review was performed for Resident 30 with LN5. LN5 confirmed there was no care plan for Resident 30 for self-administration of bedside medication. LN5 confirmed there should have been a care plan and interventions for self-administration of bedside medication. During a review of the facility's policy and procedure titled, Medication Storage: Medication Bedside Storage (March 2024), indicated in part, .bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team (IDT). (continued on next page) 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 5 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 03/13/2025 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)