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San Pedro Manor

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About San Pedro Manor

General Information

Legal Business NameSouthwest Ltc-San Pedro, Ltd
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareFebruary 18, 1987 (30 years)
Capacity150
Residents85
Percent Occupied57%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for San Pedro Manor

San Pedro Manor
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

September 17, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
KSomeImmediate JeopardyComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

July 16, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionSmoke barrier doors that can resist smoke for at least 20 minutes.
FManyPotential for HarmFire Safety InspectionProtected exits that allow the resident to escape the building.
ESomePotential for HarmHealth InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionEnsure residents maintain acceptable nutritional status.
ESomePotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
ESomePotential for HarmFire Safety InspectionProper medical gas storage and administration areas.
ESomePotential for HarmHealth InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmFire Safety InspectionFire resistant room wall surfaces.
ESomePotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

October 23, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

October 8, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

September 24, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmComplaintKeep residents' personal and medical records private and confidential.

August 8, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

May 7, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
HSomeActual HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
FManyPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
FManyPotential for HarmHealth InspectionHave a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.
FManyPotential for HarmHealth InspectionMake sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
GFewActual HarmHealth InspectionEnsure residents maintain acceptable nutritional status.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide bedrooms that don't allow residents to see each other when privacy is needed.
ESomePotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmComplaint+InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmComplaint+InspectionMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionKeep complete, dated laboratory records in the resident's file.
ESomePotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
ESomePotential for HarmHealth InspectionQuickly tell the resident's doctor the results of laboratory tests.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
ESomePotential for HarmHealth InspectionAssure that each residentís assessment is updated at least once every 3 months.
ESomePotential for HarmHealth Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
ESomePotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
ESomePotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
ESomePotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
BSomePotential for Minimal HarmHealth InspectionGive residents a notice of rights, rules, services and charges.

April 30, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
FManyPotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
FManyPotential for HarmFire Safety InspectionPortable fire extinguishers.
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
FManyPotential for HarmFire Safety InspectionExits that are accessible at all times.
FManyPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
ESomePotential for HarmFire Safety InspectionProper facilities for the use and storage of combustible liquids.
ESomePotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
ESomePotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
ESomePotential for HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
ESomePotential for HarmFire Safety InspectionProper stairway enclosures and vertical shafts.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of San Pedro Manor require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 5min
2hr 20min
ReportedExpected
CNA
1hr 10min
40min
ReportedExpected
LPN
35min
1hr 15min
ReportedExpected
RN
3hr 50min
4hr 15min
ReportedExpected
Total Nursing

This facility also provides approximately 30min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

80.8%
77.9%
77.9%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
75.6%
84.0%
94.5%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
50.0%
-
-
46.9%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
19.0%
20.0%
10.3%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
14.0%
32.7%
35.3%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
10.4%
3.9%
0.0%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
1.6%
1.5%
5.8%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
2.2%
3.8%
11.3%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
0.0%
0.0%
0.0%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
0.0%
0.0%
0.0%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
3.8%
1.3%
2.7%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
2.2%
2.4%
4.1%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

72.5%
83.1%
74.2%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
73.5%
72.1%
72.1%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
23.7%
20.9%
27.7%
16.5%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
17.9%
6.1%
8.1%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
1.2%
6.3%
4.4%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened