San Luis Post Acute Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Jan 18, 2024

  Based on interviews, facility policy review, and review of facility documents, the facility failed to ensure all potential sources of water-borne illness were identified and monitored. This deficient practice affected all 65 residents who currently reside in the facility. Findings included: A review of the facility's undated policy titled, Legionella Water Management and Risk Reduction and Prevention Program, revealed, Our facility is committed to the prevention, detections and control of water-borne contaminants, including Legionella. The policy specified, 3. […]

• No harm, potential for more than minimal, patternF880Feb 10, 2022

  Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when the : 1) Glucometers (machine used to measure blood sugar) were cleaned and disinfected per manufacturer's instructions for use. 2) N95 respirators were disposed after use per infection control guidelines. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for patients in an already compromised condition. Findings: 1) Review of the manufacturer's instructions for use titled, Evencare G3, dated 12/18 indicated in part . The Evencare G3 Meter should be cleaned and disinfected between each patient . […]

• No harm, potential for more than minimal, isolatedF761Jul 16, 2026

  Based on observation, record review, and interview, the facility failed to securely lock medications cart, discard expired medication, and discard open single use over the counter medication. This failure had the potential to result in a residents or unauthorized personnel accessing and ingesting medication that could cause signigicant adverse effects, the use of expired medications on residents and improper administation. During a concurrent observation and interview on 7/14/2026 at 8:10 a.m. with Licensed Nurse (LVN 2), in Resident 13 and 33's room, the medication cart was left unlocked for two of two residents. LVN2 stated per policy the cart does not have to be locked when in the doorway of residents room. […]

• No harm, potential for more than minimal, isolatedF656Nov 13, 2025

  Based on interview and record review, the facility failed to develop a care plan with resident-specific interventions for 1 of 3 sampled residents (Resident 1) related to non-compliance with care and refusal to wear protective foam boots (designed to protect patient's feet-heels, ankles).This failure resulted in the development of maggots in the dorsal (upper side) wound of Resident 1's left foot and was transferred to the hospital for further evaluation and treatment. During a concurrent interview and record review, on 9/24/25, at 11:24 a.m. with the Director of Nursing (DON), the DON stated, The resident (Resident 1) was admitted on [DATE] with 10 plus wounds. All were pre-existing wounds upon admission. […]

• No harm, potential for more than minimal, isolatedF554Mar 13, 2025

  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). This failure had the potential to increase the risk for medication errors which could compromise the safety and well-being of Resident 30. […]