San Luis Care Center

In the surveyor’s words

From the most serious findings on record at San Luis Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 12, 2025

  Based on interviews and record review, the facility nursing staff failed to use the proper turning technique and ensure one of three sampled residents (Resident 1), received adequate supervision and assistance during pericare (cleaning a patient's genital and anal areas) to prevent falls when Resident 1 who was deemed fully dependent for toileting hygiene, experienced a fall on 9/7/25. The certified nursing assistant did not ensure implementation of effective intervention as the use of a draw sheet (sheet placed underneath a patient to assist with repositioning and transferring in a healthcare setting) or proper technique and positioning without draw sheet for Resident 1 in accordance with facility competency, training consistent with Resident 1's care's need. […]

• Actual harm, isolatedF600Jan 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure safety and protection for one of three sampled residents (Resident 2) was free from abuse and neglect when Resident 1 had a known history of sexual behaviors that was care planned and interventions were not implemented for Resident 1. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 neglected to implement care planned intervention leaving Resident 1 unattended. […]

• Actual harm, isolatedF656Jan 30, 2024

  Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1) when Resident 1 with known inappropriate sexual behaviors was left unattended on 12/30/23 in the dining room. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 did not implement care planned intervention to not leave Resident 1 alone with female peers. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, interview and record review, the facility failed to ensure food and ice were stored, prepared, distributed, and served in accordance with professional standards for food service safety when:1. [NAME] substances were found inside the bin in one of one ice machines located in the facility's kitchen.2. Food Service Worker (FSW) 4 was observed utilizing the kitchen sanitation bucket to sanitize food carts that did not contain the recommended concentration levels of quaternary ammonium (a group of chemicals used for killing bacteria, fungi, and viruses) for sanitization (to reduce the number of disease-causing pathogens).3. […]

• No harm, potential for more than minimal, patternF761Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (define) were locked and labeled in accordance with current accepted professional standards of practice and facility procedures for one of five sampled residents (Resident 48) and two of three medication carts when: 1. [NAME] wing medication cart contained Resident 48's inhaler medication (pressurized canister that delivers a precise, pre-measured puff of medication directly into the lungs) Budesonide-Formoterol Fumarate Aerosol (treatment for asthma and chronic obstructive pulmonary disease [COPD-chronic lung disease causing difficulty in breathing]) was found to not have an open date and beyond use date (BUD- the last date you can safely use a medication).This failure had the potential… […]