San Luis Transitional Care

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 12, 2024

  Based on observation, interview and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illnesses for eleven out of eleven residents, when food debris and a cup of apple sauce were observed under the kitchen stove. This failure had the potential to result in food contamination by attracting insects and rodents that can spread pathogenic microorganisms (germs which can cause diseases) to residents through food prepared in the facility kitchen. Findings: During a review of the facility's census (a periodic count of the facility's population), titled, (Name of facility), dated June 10, 2024, the facility census indicated there were eleven residents admitted to the facility. […]

• No harm, potential for more than minimal, isolatedF577Jul 31, 2025

  Based on observation, interview, and record review, the facility failed to have the most recent recertification survey results posted and readily accessible to residents, family members, and to the resident's legal representatives.This facility failure denied the opportunity for residents, family members, and resident legal representatives to be aware of the facility's survey results.During a concurrent observation and interview on 7/30/25 at 8:56 a.m. with Administrator Assistant (AA), the survey results or survey binder were not visible in the facility areas that are prominent and accessible to the public and residents. AA stated the survey results were in a binder that is kept inside the Administration office. […]

• No harm, potential for more than minimal, isolatedF641Jul 31, 2025

  Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a tool used to assess all residents in Medicare or Medicaid certified nursing homes) assessment accurately reflected the assessment for 2 of 8 sampled residents (Resident 11 and Resident 24) when:1. Resident 11's functional limitations in range of motion indicated the resident had no impairment for upper extremity (shoulder, elbow, wrist, hand) or lower extremity (hip, knee, ankle, foot).2. Resident 24's functional limitations in range of motion indicated the resident had upper extremity limitations but no impairment in the lower extremities. These failures had the potential to result in inaccurate care plans, inappropriate interventions, and unmet needs. 1. […]

• No harm, potential for more than minimal, isolatedF761Jul 31, 2025

  Based on observation, interview, and record review, the facility failed to ensure one expired package of Maxorb II alginate wound dressing (material applied directly onto an open wound to keep the wound clean and promote healing) was discarded and not readily available for staff use. This failure had the potential for residents to receive expired and ineffective wound dressings. During a concurrent observation and interview on [DATE] at 11:20 a.m., with the Director of Nursing (DON), one open package of Maxorb II Alginate wound dressing with an expiration date of [DATE] was observed stored in the treatment cart. DON acknowledged the Maxorb II Alginate wound dressing is expired and should have been discarded. DON stated, it was missed. […]

• No harm, potential for more than minimal, isolatedF880Jul 31, 2025

  Based on record review, observation, and interview, the facility failed to ensure standard and transmission-based precautions were followed to prevent the spread of infections when staff did not follow handwashing protocol per infection control standards to provide hand hygiene to five of eight sampled residents (Residents 25, 24, 2, 9 and 7) before residents began eating their lunch.These facility failures had the potential to transmit and spread infection to residents, visitors, and staff.During an observation on 7/28/25 at 12:11 p.m., Certified Nursing Assistant (CNA 1) placed a lunch tray on Resident #25's bedside table and did not offer hand sanitizer or hand washing before the resident started eating. […]