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.

• No harm, potential for more than minimal, widespreadF812Jul 30, 2026

  Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure the kitchen was maintained, in good repair to be able to have a cleanable surface.Findings include: I. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 8/4//26. It revealed in pertinent part, Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. […]

• No harm, potential for more than minimal, widespreadF838Jun 19, 2024

  Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations. Specifically, the facility: -Failed to update the facility assessment annually; -Failed to include all current diagnoses the facility currently cared for; and, -Failed to develop a facility assessment which included staff education and staff competencies. Findings include: I. Facility assessment The facility assessment was provided by the nursing home administrator (NHA) on 6/17/24 at 11:25 a.m. […]

• No harm, potential for more than minimal, patternF947Jun 19, 2024

  Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three of five CNAs reviewed. Specifically, the facility: -Failed to ensure CNA #3 and CNA #5 received annual dementia management training; -Failed to ensure CNA #1 received annual abuse training; and, -Failed to ensure CNA #5 received 12 hours of annual training. Findings include: I. Record review of insufficient in-service training in the last 12 months for three CNAs CNA #1 was hired on 9/7/22. She had not had annual abuse training in the past 12 months. CNA #3 was hired on 5/3/23. […]

• No harm, potential for more than minimal, isolatedF600Jul 30, 2026

  Based on observations, record review and interviews, the facility failed to ensure one (#60) of three residents reviewed for abuse were kept free from abuse out of 34 sample residents.Specifically, the facility failed to protect Resident #60 from sexual abuse by Resident #48.Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, revised 7/18/23, was received from the nursing home administrator (NHA) on 7/27/26 at 11:34 a.m. It revealed in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. […]

• No harm, potential for more than minimal, isolatedF656Jul 30, 2026

  Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two (#7 and #13) of seven residents reviewed for care plans out of 34 sample residents.Specifically, the facility failed to:-Develop and implement a person-centered comprehensive care plan which included Resident #7's use of antipsychotic medications; and,-Develop and implement a person-centered comprehensive care plan which included Resident #13's oxygen use. Findings include: I. Facility policy and procedure The Comprehensive Care Plans and Revisions policy, revised August 2025, was provided by the nursing home administrator (NHA) on 8/4/26 at 10:40 a.m. […]